Teun Zuiderent-Jerak

Editorial Introduction: Unpacking ‘Intervention’ in Science and Technology Studies

In science and technology studies (STS) as elsewhere, continuous appeals are appearing, urging research to ‘get real’ (Bal et al., 2004) by which is meant to demonstrate usefulness, not just academically, but also in ‘practical’ environments such as policy and business.

Guidelines should reflect all knowledge, not just clinical trials.

Over the past 20 years, evidence based medicine has had a substantial influence on clinical decision making throughout the developed world. It now underpins healthcare policy and the burgeoning industry of clinical guideline development. Two problems have resulted. Firstly, so called high level evidence is increasingly equated with strong recommendations; and secondly, evidence other than that derived from randomised controlled trials (RCTs) is seen as intrinsically less valuable or reliable. The concept of a hierarchy of evidence with RCTs at the top is deeply ingrained, despite Sackett and colleagues’ warning that evidence based medicine “is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.”1 They pointed out that RCTs and systematic reviews of RCTs will provide the most reliable evidence that a therapy will do more good than harm but acknowledged that “some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted.” They also made clear that other questions, such as those about diagnostic tests and prognosis, can only be answered using other forms of evidence. In his 2008 Harveian oration, Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence (NICE), elegantly analysed the strengths and …

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.

An empirical study of patient participation in guideline development : exploring the potential for articulating patient knowledge in evidence-based epistemic settings

Patient participation on both the individual and the collective level attracts broad attention from policy makers and researchers. Participation is expected to make decision making more democratic and increase the quality of decisions, but empirical evidence for this remains wanting.

Framing Reflexivity in Quality Improvement Devices in the Care for Older People

Health care organizations are constantly seeking ways to improve quality of care and one of the often-posed solutions to deliver ‘good care’ is reflexivity. Several authors stress that enhancing the organizations’ and caregivers’ reflexivity allows for more situated, and therefore better care. Within quality improvement initiatives, devices that guarantee quality are also seen as key to the delivery of good care. These devices do not solely aim at standardizing work practices, but are also of importance in facilitating reflexivity. In this article, we study how quality improvement devices position the relationship between situated reflection and standardization of work processes. By exploring the work of Michel Callon, Michael Lynch, and Lucy Suchman on reflexivity in work practices, we study the development and introduction of the Care Living Plan. This device aimed to transform care organizations of older people from their orientation towards the system of care into organizations that take a client-centred approach. Our analysis of the construction of specific forms of reflexivity in quality devices indicates that the question of reflexivity does not need to be opposed to standardization and needs to be addressed not only at the level of where reflexivity is organizationally situated and who gets to do the reflecting, but also on the content of reflexivity, such as what are the issues that care workers can and cannot reflect upon. In this paper we point out the theoretical importance of a more detailed empirical study of the framing of reflexivity in care practices.

The practice of markets in Dutch health care: are we drinking from the same glass?

Health Economics, Policy and Law / Volume 6 / Issue 01 / January 2011, pp 139 145 DOI: 10.1017/S1744133110000368, Published online: 26 January 2011 Link to this article: http://journals.cambridge.org/abstract_S1744133110000368 How to cite this article: Roland Bal and Teun Zuiderent-Jerak (2011). The practice of markets in Dutch health care: are we drinking from the same glass?. Health Economics, Policy and Law, 6, pp 139-145 doi:10.1017/ S1744133110000368 Request Permissions : Click here

Diagnostic Work through Evidence-Based Guidelines: Avoiding Gaps Between Development and Implementation of a Guideline for Problem Behaviour in Elderly Care

Diagnostic work is the reflexive work of figuring out what issues are at stake and determining the scope for action. This work is not generally accommodated by evidence-based guidelines, which generally promote a uniform, predefined approach to solving healthcare problems that risk narrowing the opportunities for diagnostic work in healthcare practice. Consequently, guidelines are often criticised as too general to solve situated, individual healthcare problems and gaps between guidelines and their implementation are often reported. The Netherlands has developed a guideline for problem behaviour in elderly care, explicitly designed for diagnostic work, thus stimulating a situated approach. Relational problem behaviour is highly embedded in its context. The guideline stimulates diagnostic work, which helps to unravel problem behaviour and is opening alternatives in elderly care. Diagnostic work does not transfer guideline development problems to healthcare practice, but simply structures the decision-making process without giving a predefined answer. Diagnostic work is thus important to consider in order to avoid a gap between guideline development and implementation.

Patients and their Problems: Situated Alliances of Patient-Centred Care and Pathway Development

It is 11:00 a.m. on a May morning in a hospital in a large city in the Netherlands. This hospital, which we will call Hospital E, is a university medical center and we are observing the work at the haematology/oncology outpatient clinic and treatment center. Most of the patients here are tertiary referrals who can no longer get the care they need in regional hospitals. Patients are referred by hospitals in the region but also by clinics throughout the Netherlands: particular forms of care offered are known to be of very high quality in Hospital E. We are witnessing a common phenomenon at this time in the morning in the treatment center of the haematology/oncology ward: all the chairs are filled by people receiving chemotherapy and there are still many patients waiting for their consultation with their haematologist or oncologist.

Op weg naar duurzaam verbeteren in de langdurige zorg

SamenvattingHet nationaal verbeterprogramma Zorg voor Beter beoogt een duurzame kwaliteitsverbetering in de langdurige zorg die verspreid kan worden binnen en buiten de deelnemende instellingen. Het evaluatieonderzoek richt zich op de vraag welke condities op programma- en organisatieniveau aanwezig moeten zijn om op de korte termijn tot effectieve kwaliteitsverbetering te komen en om deze resultaten en nieuwe werkwijzen ook vast te houden en te verspreiden. De korte termijn resultaten van de verbetertrajecten blijken veelal positief te zijn. De projectspecifieke doelstellingen worden echter niet altijd door de beoogde 70% van de teams behaald en er is grote variatie tussen teams en trajecten. De mate van evidentie van effectiviteit van interventies kan bijdragen aan het meetbaar maken van resultaten en het formuleren van haalbare en uitdagende doelstellingen, maar blijkt niet doorslaggevend te zijn voor de effectiviteit van een verbetertraject. Observaties binnen de trajecten Decubitus en Eten en Drinken laten zien dat de organisatorische context waarbinnen een verbeterteam tot kwaliteitsverbetering moet komen essentieel is. Om te leren wat duurzaam verbeteren betekent, zijn beschrijvingen van wat er op de werkvloer plaatsvindt noodzakelijk.AbstractTowards sustainable improvement in longterm care? Intermediate results of the Care for Better quality improvement collaborative The nationwide quality improvement collaborative Care for Better aims at stimulating sustainable quality improvement that can be spread within longterm care. The evaluation study focuses on providing a better understanding of which conditions on the program and organisational level should be present to realise not only short term improvements in quality of care, but also to sustain and spread results and new working methods. With respect to the results on short term, the overall results of the improvement trajectories are positive. However, projectspecific goals are not always realised by 70% of the teams, as was aimed for, and large variation exists between teams and trajectories. The evidence base of effectiveness of interventions may support in making results measurable and formulating achievable and challenging goals. This is, however, no precondition for an effective improvement project. Our observations within the pressure ulcers and eating and drinking trajectories show that the organisational context within which improvement teams have to realise improvements in quality of care are important. To learn about sustainability real life descriptions of the improvement practices are necessary.