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Quality improvement within nonprofit social service providers
Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).ORCID iD: 0000-0001-8070-4718
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

As a relatively new phenomenon in 2009, Swedish nonprofit social service providers proposed quality improvement as a way to reduce mistakes, use resources more effectively and meet the needs and expectations of clients in a better way. Although similar experiences have been studied in health care, the transfer of quality improvement to nonprofit social services gives a possibility for more knowledge on what enables, and constrains, systematic quality improvement in this specific context.

This thesis is based on five years of supporting quality improvement in the Swedish nonprofit welfare sector. Specifically, it builds knowledge on which active mechanisms and enabling or constraining structures exist for nonprofit social service quality improvement. By studying quality improvement projects that have been conducted in the development program Forum for Values, critical cases and broad overviews are found valuable. These cases have resulted in four papers on quality improvement in nonprofit social services. The papers include: critical cases from a nursing home for elderly and a daycare for disabled children (Paper I); a critical case from a sheltered housing (Paper II); an overview of performance measurements in 127 quality improvement projects (Paper III); and an analytical model of how improvement policy and practice are bridged by intermediaries (Paper IV). In this thesis, enabled or constrained events and activities related to Deming's system of profound knowledge are identified from the papers and elaborated upon. As a basis for transforming practice into continuous improvement, profound knowledge includes the four knowledge domains: appreciation of a system, theory of knowledge, understanding of variation and psychology of change. From a realist perspective, the identified events are seen as enabled or constrained by mechanisms and underlying regularities, or structures, in the context of nonprofit social services.

The emerging mechanisms found in this thesis are: describing and reflecting upon project relations; forming and testing a theory of action; collecting and displaying measurable results over time; and engaging and participating in a development program. The structures that enable these mechanisms are: connecting projects to shared values such as client needs; local ownership of what should be measured; and translating quality improvement into a single practice. Constraining structures identified are: a lack of generalizable scientific knowledge and inappropriate or missing infrastructure for measurements.

Reflecting upon the emergent structures of nonprofit social services, the role of political macro structures, reflective practice, competence in statistical methods and areas of expertise becomes important. From this discussion and the findings some hypotheses for future work can be formulated. First, the identified mechanisms and structures form a framework that helps explain why intended actions of quality improvement occur or not. This frameworkcan be part of formulating a program theory of quality improvement in nonprofit social services. With this theory, quality improvement can be evaluated, reflected upon and further developed in future interventions. Second,new quality improvement interventions can be reproduced more regularly by active work with known enablers and constraints from this program theory. This means that long-lasting interventions can be performed and studied in a second generation of improvement efforts. Third, if organizations integrate quality improvement as a part of their everyday practice they also develop context-specific knowledge about their services. This context-specific knowledge can be adopted and further developed through dedicated management and understanding of variation.

Thus, if enabling structures are invoked and constraining structures handled, systematic quality improvement could be one way to integrate generalizable scientific knowledge as part of an evidence-creating practice.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2016. , 103 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 68
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:hj:diva-29788ISBN: 978-91-85835-67-6 (print)OAI: oai:DiVA.org:hj-29788DiVA: diva2:920556
Public defence
2016-05-20, Forum Humanum, School of Health and Welfare, Jönköping, 13:00
Opponent
Supervisors
Available from: 2016-04-18 Created: 2016-04-18 Last updated: 2016-12-02Bibliographically approved
List of papers
1. Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies
Open this publication in new window or tab >>Prospects and problems of transferring quality-improvement methods from health care to social services: two case studies
2014 (English)In: The Permanente Journal, ISSN 1552-5767, E-ISSN 1552-5775, Vol. 18, no 2, 38-42 p.Article in journal (Refereed) Published
Abstract [en]

Introduction: This study examines the use of quality-improvement(QI) methods in social services. Particularly the keyaspects—generalizable knowledge, interprofessional teamwork,and measurements—are studied in projects from the QI programForum for Values in Sweden.Methods: This is a mixed-method case study. Two projectsusing standard QI methods and tools as used in health carewere chosen as critical cases to highlight some problems andprospects with the use of QI in social services. The cases wereanalyzed through documented results and qualitative interviewswith participants one year after the QI projects ended.Results: The social service QI projects led to measurableimprovements when they used standard methods and tools forQI in health care. One year after the projects, the improvementswere either not continuously measured or not reported in anyinfrastructure for measurements. The study reveals that socialservices differ from health care regarding the availability and useof evidence, the role of professional expertise, and infrastructurefor measurements.Conclusions: We argue that QI methods as used in healthcare are applicable in social services and can lead to measurableimprovements. The study gives valuable insights for QI,not only in social services but also in health care, on howto assess and sustain improvements when infrastructures formeasurements are lacking. In addition, when one forms QIteams, the focus should be on functions instead of professions,and QI methods can be used to support implementation ofevidence-based practice.

National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-25545 (URN)10.7812/TPP/13-078 (DOI)24867549 (PubMedID)2-s2.0-84922218226 (Scopus ID)
Available from: 2015-01-08 Created: 2015-01-08 Last updated: 2017-04-20Bibliographically approved
2. Quality improvement in the case of sheltered housing
Open this publication in new window or tab >>Quality improvement in the case of sheltered housing
(English)Article in journal (Other academic) Submitted
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-29786 (URN)
Available from: 2016-04-18 Created: 2016-04-18 Last updated: 2016-04-18
3. Process or result-oriented performance measures in improvement of Not for Profits
Open this publication in new window or tab >>Process or result-oriented performance measures in improvement of Not for Profits
(English)Manuscript (preprint) (Other academic)
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hj:diva-29787 (URN)
Available from: 2016-04-18 Created: 2016-04-18 Last updated: 2016-04-18
4. Managing the gap between policy and practice through Intermediaries for Quality Improvement
Open this publication in new window or tab >>Managing the gap between policy and practice through Intermediaries for Quality Improvement
2014 (English)In: Offentlig Förvaltning. Scandinavian Journal of Public Administration, ISSN 2000-8058, E-ISSN 2001-3310, Vol. 18, no 4, 73-89 p.Article in journal (Refereed) Published
Abstract [en]

A gap exists between policymaking for quality improvement and the realization of these policies in practice. Using previous research on intermediaries, a conceptual model of an Intermediary for Quality Improvement (IQI) is developed. The model highlights the characteristics of structural positions, mediating approaches, and duration as a way to describe an IQI. The conceptual model is used to examine two cases in which Famna, the Swedish Association for Non-profit Health and Social Service Providers, has supported both policymaking and the implementation of policies at a provider level. The cases are the national strategy for quality improvement by open comparisons in health care and social services and a new regulation on quality management systems in health care and social services. Using the concept of an IQI deepens the understanding of how top-down and bottom-up perspectives may be managed to realize good quality of services.

Keyword
Intermediaries, Quality, Policy, Implementation, Improvement
National Category
Other Social Sciences
Identifiers
urn:nbn:se:hj:diva-25546 (URN)
Available from: 2015-01-08 Created: 2015-01-08 Last updated: 2017-04-20Bibliographically approved

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