Roland Bal

Paradox of Scientific Authority: the Role of Scientific Advice in Democracies

Today, scientific advice is asked for (and given) on questions ranging from stem-cell research to genetically modified food. And yet it often seems that the more urgently scientific advice is solicited, the more vigorously scientific authority is questioned by policy makers, stakeholders, and citizens. This book examines a paradox: how scientific advice can be influential in society even when the status of science and scientists seems to be at a low ebb. The authors do this by means of an ethnographic study of the creation of scientific authority at one of the key sites for the interaction of science, policy, and society: the scientific advisory committee. The Paradox of Scientific Authority offers a detailed analysis of the inner workings of the influential Health Council of the Netherlands (the equivalent of the National Academy of Science in the United States), examining its societal role as well as its internal functioning, and using the findings to build a theory of scientific advising. The question of scientific authority has political as well as scholarly relevance. Democratic political institutions, largely developed in the nineteenth century, lack the institutional means to address the twenty-first centurys pervasively scientific and technological culture; and science and technology studies (STS) grapples with the central question of how to understand the authority of science while recognizing its socially constructed nature.

Performance Regimes in Health Care: Institutions, Critical Junctures and the Logic of Escalation in England and the Netherlands

The Netherlands and England are near neighbours whose health care systems have much in common and whose health policy communities have also usually been well aware of what is going on in the other country. Nevertheless, for the two decades from 1982, England adopted and repeatedly redeveloped performance indicator (PI) systems in the health care field while the Netherlands virtually shunned them. A broad institutional explanation for this divergence is provided by England’s majoritarian and adversarial political system that leaves governments with fewer constraints and compromises than in the more consociational Dutch system. More recently, however, a Dutch national system of health care PIs has appeared, suggesting that this explanation needs to be supplemented. This paper draws on an empirical study of PI systems in the two countries over the period from 1982 to 2007 to suggest that two further factors are at work. Established institutional patterns may be disrupted by ‘punctuations’, while technical and political factors endogenous to PI systems may exert a logic of their own.

Building an inter-organizational communication network and challenges for preserving interoperability

BACKGROUND The ideal scenario for information technology to bridge information gaps between primary and secondary healthcare and to improve the quality of healthcare in the medication process is to build an interoperable communication network. This type of undertaking requires diverse information systems to be integrated, and central to this are the preservation of data integrity and the integration of different pieces of patient data. OBJECTIVES AND METHODOLOGY: In this study, we focused on sources of challenges to the integration process and to the building of an interoperable communication network. Interviews, document analysis, and observations were conducted to evaluate the integration process in a project that involved medication data communication between primary healthcare providers (i.e., general practitioners and community pharmacists) and secondary healthcare providers (i.e., hospital pharmacists and specialist physicians). RESULTS The project encountered numerous integration problems, many of which persisted even after extensive technical intervention. An analysis of the problems revealed that they were mostly rooted either in problematic integration of work processes or in the way the system was used. Despite the projects ideal technical condition, the integration could be accomplished only by applying human interfaces. CONCLUSION The main challenge to building interoperable communication network does not lie in technical integration. The real problem occurs when the technical linkage is implemented without the work processes being aligned and integrated.

Telemedicine in interdisciplinary work practices: On an IT system that met the criteria for success set out by its sponsors, yet failed to become part of every-day clinical routines

BackgroundInformation systems can play a key role in care innovations including task redesign and shared care. Many demonstration projects have presented evidence of clinical and cost effectiveness and high levels of patient satisfaction. Yet these same projects often fail to become part of everyday clinical routines. The aim of the paper is to gain insight into a common paradox that a technology can meet the criteria for success set out at the start of the project yet fail to become part of everyday clinical routines.MethodsWe evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were further assessed by trained technicians in the hospital. Over a period of three years, we conducted interviews with the project team and the users about the workability of the system and its integration in practice. Beside the interviews, we analyzed record data to measure the quality of the images. We compared the qualitative accounts with these measurements.ResultsAccording to our measurements, the quality of the images was at least satisfactory in 90% of the cases, i.e. the images could be used to screen the patients – reducing the workload of the ophthalmologist considerably. However, both the ophthalmologist and the optometrists became increasingly dissatisfied respectively with the perceived quality of the pictures and the perceived workload.Through a detailed analysis of how the professionals discussed the quality of the pictures, we re-constructed how the notion of quality of the images and being a good professional were constructed and linked. The IT system transformed into a quality system and, at the same time, transformed the notions of being a good professional. While a continuous dialogue about the quality of the pictures became an emblem for the quality of care, this dialogue was hindered by the system and the way the care process was structured.ConclusionTo conceptualize what telemedicine does in interdisciplinary work practices, a fine-tuned analysis is needed to assess how IT systems re-shape the social relations between professional groups. Such transformations should not be exclusively attributed to the technology itself or to the professionals working with it. Instead we need to assess these technologies through an empirically grounded study of the sociotechnical functioning of telemedicine.

Creating effective quality-improvement collaboratives: a multiple case study

Objective To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness. Study setting 182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaboratives (QICs) focusing on patient safety and autonomy. Study design Multiple case before–after study. Data collection 75 team leaders completed a written questionnaire at the end of each QIC on achievability and degree of challenge of targets and measurability of progress. Main outcome indicators were collaborative-specific measures (such as prevalence of pressure ulcers). Principal findings The degree of effectiveness and percentage of teams realising targets varied between collaboratives. Collaboratives also varied widely in perceived measurability (F=6.798 and p=0.000) and with respect to formulating achievable targets (F=6.566 and p=0.000). The Problem Behaviour collaborative scored significantly lower than all other collaboratives on both dimensions. The collaborative on Autonomy and control scored significantly lower on measurability than the other collaboratives. Topics for which there are best practices and evidence of effective interventions do not necessarily score higher on effectiveness, measurability, achievable and challenging targets. Conclusions The effectiveness of a QIC is associated with the efforts of programme managers to create conditions that provide insight into which changes in processes of care and in client outcomes have been made. Measurability is not an inherent property of the improvement topic. Rather, creating measurability and formulating challenging and achievable targets is one of the crucial tasks for programme managers of QICs.

Opening the black box of quality improvement collaboratives: An Actor-Network theory approach

BackgroundQuality improvement collaboratives are often labeled as black boxes because effect studies usually do not describe exactly how the results were obtained. In this article we propose a way of opening such a black box, by taking up a dynamic perspective based on Actor-Network Theory. We thereby analyze how the problematisation process and the measurement practices are constructed. Findings from this analysis may have consequences for future evaluation studies of collaboratives.MethodsIn an ethnographic design we probed two projects within a larger quality improvement collaborative on long term mental health care and care for the intellectually disabled. Ethnographic observations were made at nine national conferences. Furthermore we conducted six case studies involving participating teams. Additionally, we interviewed the two program leaders of the overall projects.ResultsIn one project the problematisation seemed to undergo a shift of focus away from the one suggested by the project leaders. In the other we observed multiple roles of the measurement instrument used. The instrument did not only measure effects of the improvement actions but also changed these actions and affected the actors involved.ConclusionsEffectiveness statistics ideally should be complemented with an analysis of the construction of the collaborative and the improvement practices. Effect studies of collaboratives could benefit from a mixed methods research design that combines quantitative and qualitative methods.

A framework and a measurement instrument for sustainability of work practices in long-term care

BackgroundIn health care, many organizations are working on quality improvement and/or innovation of their care practices. Although the effectiveness of improvement processes has been studied extensively, little attention has been given to sustainability of the changed work practices after implementation. The objective of this study is to develop a theoretical framework and measurement instrument for sustainability. To this end sustainability is conceptualized with two dimensions: routinization and institutionalization.MethodsThe exploratory methodological design consisted of three phases: a) framework development; b) instrument development; and c) field testing in former improvement teams in a quality improvement program for health care (N teams = 63, N individual = 112). Data were collected not until at least one year had passed after implementation.Underlying constructs and their interrelations were explored using Structural Equation Modeling and Principal Component Analyses. Internal consistency was computed with Cronbachs alpha coefficient. A long and a short version of the instrument are proposed.ResultsThe χ2- difference test of the -2 Log Likelihood estimates demonstrated that the hierarchical two factor model with routinization and institutionalization as separate constructs showed a better fit than the one factor model (p < .01). Secondly, construct validity of the instrument was strong as indicated by the high factor loadings of the items. Finally, the internal consistency of the subscales was good.ConclusionsThe theoretical framework offers a valuable starting point for the analysis of sustainability on the level of actual changed work practices. Even though the two dimensions routinization and institutionalization are related, they are clearly distinguishable and each has distinct value in the discussion of sustainability. Finally, the subscales conformed to psychometric properties defined in literature. The instrument can be used in the evaluation of improvement projects.

Disease management projects and the Chronic Care Model in action: baseline qualitative research

BackgroundDisease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in the Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams.MethodsEleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project’s chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders’ action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework.ResultsThis analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved.ConclusionsAt the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader’s point of view.

Cost-effectiveness of a pressure ulcer quality collaborative

BackgroundA quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective.MethodsWe used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained.ResultsIncidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by €2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained.ConclusionsDuring the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.

Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation

BackgroundTailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.MethodsAn ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically.ResultsOur ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations.ConclusionAs tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.