Background: Clinical practice improvements based on quality-register data are influenced by multiple factors. Although there is agreement that information from quality registers is valuable for quality improvement, practical ways of organising register use have been notoriously difficult to realise. The present study sought to investigate the mechanisms that lead various clinicians to use quality registers for improvement.

Methods: This research involves studying individuals’ decisions in response to a Swedish programme focusing on increasing the use of quality registers. Through a case study, we focused on heart failure care and its corresponding register: the Swedish Heart Failure Register. The empirical data consisted of a purposive sample collected longitudinally by qualitative methods between 2013 and 2015. In total, 18 semi-structured interviews were carried out. We used realist evaluation to identify contexts, mechanisms, and outcomes.

Results: We identified four contexts – registration, use of output data, governance, and improvement projects – that provide conditions for the initiation of specific mechanisms. Given a professional theoretical perspective, we further showed that mechanisms are based on the logics of either organisational improvement or clinical practice. The two logics offer insights into the ways in which clinicians choose to embrace or reject certain registers’ initiatives.

Conclusions: We identified a strong path dependence, as registers have historically been tightly linked to the medical profession’s competence. Few new initiatives in the studied programme reach the clinical context. We explain this through the lack of an organisational improvement logic and its corresponding mechanisms in the context of the medical profession. Implementation programmes must understand the logic of clinical practice; that is, be integrated with the ways in which work is carried out in everyday practice. Programmes need to be better at helping core health professionals to reach the highest standards of patient care.

In this study we adopt a critical perspective and explore different coaching styles in quality improvement (QI) work in the provision of healthcare. Coaching has gained attention as an effective way to enhance QI in healthcare. This study investigates how coaching is realised in terms of learning: What kinds of learning ideals pervade QI coaching, and how is support for learning realised, given the prevailing conditions in a contemporary healthcare system? For the purpose of this case study, a group of coaches exchanged experiences about their pedagogic roles and the strategies that they employed, on four occasions, over a period of 4 months. The conversations were filmed and then analysed, using critical discourse analysis as an analytic framework. Three parallel styles of coaching were identified, which were symbolised by (1) a pointing, (2) a bypassing and (3) a guiding discourse. No persistent dominance of any one of the discourses was found, which suggests that there exists an ever-present tension between the pointing and guiding pedagogies of coaching activities. The findings indicate that QI coaching in healthcare is more complex than previous conceptualisations of coaching. Additionally, the findings present a new, ‘bypassing’ coaching style which the coaches themselves were not fully aware of.

In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s.

The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies.

The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change.

Context

Observations were made at clinical ward meetings and process team meetings at an orthopedic- and rheumatology clinic in Sweden. Mostly nurses and assistant nurses participated along with their manager at the clinical ward meeting. The process team consists of staff from the patient’s process which in this case includes physicians, nurses, physiotherapists and occupational therapists from both primary and specialist care. The improvement work in both meetings is facilitated by a developmental leader.

Problem 

Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. Given that learning sometimes is taken for granted in quality improvement work, this study set out to address what actually is said when professionals discuss improvements and how discursive patterns influence learning.

 Assessment of problem and analysis of its causes

 The study has an explorative qualitative design to investigate how discursive patterns occur in quality improvement conversations which means that quantified measuring was not appropriate.

 The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings. Assessment of problem and analysis of causes was a mutual effort from both researchers and staff. Ideas for improvements came up during the learning seminars when the researchers highlighted findings.

 Intervention 

The study had not an interventional purpose.

Study design 

A starting point in the methodology is that language is tightly connected to social learning. Five observations of quality improvement conversations were made and transcribed to texts. The conversations were analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). A framework of specific questions was constructed to guide the analytical process in Faircloughs’ three steps of description, interpretation and explanation.

Strategy for change 

As the study used a participatory research design, implementation, in its right term, was not needed because the staff saw what they needed to improve along with feedback and analysis from the researchers.

Measurement of improvement 

Methods, see questions 3 and 5 above.

Results

Four discursive patterns were found in the talk of improvements. We have named them the marketization pattern, the care-for-all pattern, the medical pattern and the value pattern. The marketization pattern dominates the dialogue while money is linked to quality control. The results also showed a balance between discourse patterns when money incentives were absent. In other words, professionals tend to integrate complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when improvement goals are linked to monetary incentives the professionals talk about what is the most profitable thing to do.  

Effects of changes 

See questions 3 and 4 above.

Lessons learnt 

The discourse order indicates that market principles impact on learning in terms of displacement effects. In a short term perspective, professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside.

The study implicates the importance of a balancing perspective on quality management if no quality aspect is to be left behind. Replicating studies in other contexts would be interesting to perform.

Message for others: What is the main message based on the experience that you describe here that you would like to convey to others? Discuss what your findings mean for patients and/or systems of care.

Money incentives promote learning about economical values and not what creates value for patients.

Please declare any conflicts of interest below 

The study is part of the research project Bridging the Gaps which is financed by Vinnvård. Otherwise no other conflict of interest is to be declared.

Introduction

Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. In practice, that means new payment systems, increased transparency and comparisons to relate to. Given that learning sometimes is taken for granted in implementation work, what is actually said when professionals discuss improvements? This study identifies discursive patterns when an orthopedic team discusses their improvement data and problemetizes how these patterns create conditions for learning.

Methods

Five observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. The conversations were transcribed and then analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). The study used a method of interpretation with Habermas’ societal theory of system and lifeworld as a point of departure.

Results

Four different discursive patterns were found that deal with: (1) marketization, (2) equal care, (3) medical reasoning and, (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The results also show a balance between discourse patterns when money incentives were absent. In other words, professionals can handle complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when implementation goals are linked to monetary incentives, the professionals turn to act for what is the most profitable thing to do.

Discussion

The discourse order indicates that market principles impact on learning in terms of displacement effects. In a short term perspective, professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside. The study implicates the importance of a balancing perspective on quality management if no quality aspect is to be left behind.

Introduction: The clinical microsystem (CMS)approach is widely used and is perceived as helpfulin practice but, we ask the question: “Is its learningpotential sufficiently utilized?”

Objectives: Toscrutinize aspects of learning within the CMSframework and to clarify the learning aspects theframework includes and thereby support theframework with the enhanced learning perspectivethat becomes visible.

Methods: Literature on theCMS framework was systematically searched andselected using inclusion criteria. An analytical toolwas constructed in the form of a theoretical lensthat was used to clarify learning aspects that areassociated with the framework.

Findings: Theanalysis revealed 3 learning aspects: (1) The CMSframework describes individual and social learningbut not how to adapt learning strategies forpurposes of change. (2) The metaphorical languageof how to reach a holistic health care system foreach patient has developed over time but can stillbe improved by naming social interactions totranscend organizational boundaries. (3) Powerstructures are recognized but not as a characteristicthat restricts learning due to asymmetriccommunication.

Conclusion: The “lens” perspectivereveals new meanings to learning that enhance ourunderstanding of health care as a social system andprovides new practical learning strategies.

Purpose

This study bases its interest in the discursive importance for change and how negotiation can be supported. The purpose of this study was to analyze what is at stake in the interface between adaptation and change, how improvements are negotiated, and if the negotiation differs between a uniform and a networked community of practice.

Theoretical framework

The result is explained in relation to a social learning theory, Communities of Practice and its scientific field. A complementary methodology of critical discourse analysis is used to investigate genre and style of the discourses that are produced in the negotiation of improvements.

Design

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. Ward staff meetings represent a tightly coupled community and a process team represents a network of communities. The process team connects all communities that shape a process of care for a particular subgroup of patients. Two samples of recurrent central themes were chosen from the empirical data for more detailed transcriptions and a critical discourse analysis was made in three steps: descriptive, interpretive, and an explaining analysis.

The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings.

Results

Traditional standards were at stake in the interface between adaptation and change and the negotiation needed to be explicit if change was going to happen. In the tightly coupled community standards were taken for granted and not explicitly negotiated. Initiatives of change had no impact because they were not discursively valued compared with old ones. In contrast to the ward meeting, the team had to negotiate and explain old standards as well as new ones because of their unfamiliar relation to each other. As they argued they got hold of new meanings that could be more valuable for patients.

Limitations

This study has been limited to analyze how the interactive dialogue is produced and not the participation in a more quantitative sense. The analysis show supportive and equal participation from the samples that were selected. However, if you had looked at the overall texts and made a quantitative analysis of speech space it might have shown inequalities.

Practical implications

The study implicates that external coaches of improvement work could be useful in tightly coupled communities of practice. An external coach can help the community create awareness of taken for granted standards and support an explicit negotiation.

Value

The contribution of how to support improvement dialogues can be transferable and universal to other organizations that integrate both uniform and networked communities.

Background

Clinical Microsystem theory underlines the importance of doing improvements both in and between communities. The design and improvements of each clinical microsystem is as important as the pathway between microsystems. But how are uniform or differentiated standards negotiated in a community of practice compared to a network of practices?

Aim

The aim was to analyze discursive differences in the negotiation depending on whether practices were shared or differentiated. The study analyzed the interactive negotiation in a tightly coupled Community of practice compared with a loosely coupled Network of practices, with an interest of investigating what kind of pedagogical support different improvement groups need.

Method

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. A clinical ward meeting represents a tightly coupled Community of practice and a process team represents a loosely coupled network of practices. Critical discourse analysis was used and the social learning theory Communities of practice was the theoretical framework that explained the findings.

Findings

The analysis showed that the most important difference between a tightly coupled community of practice and loosely coupled network of practices is the explicit character of the negotiation. At the clinical ward meeting standards and traditional hierarchy were taken for granted and not explicitly negotiated. Initiatives of change had no impact because new standards were not discursively valued compared with old ones. In contrast to the ward meeting, the team had to negotiate and explain old standards as well as new ones because of the unfamiliar relation to each other. As they argued they mutually found out new meanings, and new solutions that could be more valuable for patients.

Discussion

Given the discursive perspective, the study shows that in the interface between adaptation and change the negotiation needs to be explicit if change is going to happen. This explicit improvement negotiation was more easily done in a differentiated practice which contradicts other research of Communities of practice in health care. Anglo-Saxon research has shown the difficulties of learning and change in networked practices because of rivalry between professionals or specialties. One explanation could be differences in culture between Swedish and Anglo-Saxon hierarchies in health care which has to be considered in future Community of practice analyzes.

Practical implications

The study indicates that external coaches of improvement work could be useful in tightly coupled communities of practice. An external coach can help the community create awareness of taken for granted issues and support an explicit negotiation.           

Background

Sometimes learning is taken for granted in improvement practices, but what lies behind the taken for granted assumption? What is actually said when professionals discuss improvements and how does that impact on learning?

Healthcare, at least in Sweden, has been characterized by marketization the last 30 years which ultimately is about giving more power to patients. In practice, that means new payment systems, ever-changing care processes, increased transparency and comparisons to relate to. How does that affect the improvement talk? How do professionals handle the dilemma of giving the best individual care to each patient as they have the responsibility to create equal care for all?

Objective

The aim was to identify discursive patterns in an improvement practice and to discuss their conditions for learning.

Method

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic. Both the patient’s micro- and mesosystems were observed. The conversations were analyzed through critical discourse analysis (Fairclough 1992) with connection to a societal theory (Habermas 1987).

Findings

Four different discursive patterns were found that deal with (1) marketization, (2) equal care, (3) medical reasoning and (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The findings show that professionals can handle the dilemma of improving the best individual care with equal care as long as quality measurements are not linked to payments. However, when measurements, as for example certain quality registers, are linked to monetary incentives the professionals turn to act for what is the most profitable thing to do.

Discussion

We discuss that market principles, as for example monetary quality control, impact on learning in terms of displacement effects. Professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients.

References

Fairclough, N. (1992): Discourse and Social Change. Cambridge: Polity Press.

Habermas, J. (1987). The Theory of Communicative Action, Lifeworld and System: A Critique of Functionalist Reason. Vol 2. Boston: Beacon Press.