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Guidelines can be derived from research into quality programmes
Submit responseDear Editor
I would like to thank Dr Checkland for her thoughtful comments on our paper about evaluating quality programmes. I have some sympathy with her views and for the intriguing proposal about research in this area which she makes. I would agree that insufficient attention has been given to how features of organisations described in organisational theory influences how quality programmes are carried through. Certainly the concept of organisational culture can be inadequate: it is often used as a lazy explanation and as an excuse for thinking about exactly what affects quality programmes and how. Our paper also emphasized how power and internal politics affect how a programme is implemented, and the point in the letter about conflict over goals in organisations is well made. The same is true about criteria for success: different actors have different criteria.
I think the key point is the question about whether “essential conditions” can be derived for all organisations to ensure successful implementation, given the complex nature of health care organisations. Dr Checkland thinks not, and that no “proscriptive quality programme” will succeed in more than one site. And certainly, both observation and TQM advice suggest that each programme must be designed and regularly replanned to suit the organisation and its situation.
The research we described included empirical studies which examined associations between factors and improved quality in each organisation and draw together these findings in an aggregate model. Such models suggest factors which are common when all the findings are pooled. The model does not predict which will be the most important in a particular organisation in particular circumstances. The influences only appear in the aggregate, and suggest that some of these influences might be operating in an individual case.
Such aggregate models can be misleading if they are taken to suggest these influences apply in all situations. However, models derived in this way do give leaders a good basis for examining which factors might be important in their situation. The model does not prescribe, but gives useful guidelines for diagnosis and a local strategy. They also give useful research frameworks for case studies to discover which influences were acting in a particular situation. Case studies of different processes and methods for designing local strategies and systems can discover which are most effective for this purpose. Dr Checkland’s proposal is for a particular type of case study. The proposal is to dispense with “standard” interventions and instead to define outcomes. Organisations would be helped through action research to “work to understand their own internal dynamics, and in reaching that understanding, go on to make any changes necessary to reach the desirable outcomes”. This is an intriguing proposal and one I would support – as an experiment. It should also be evaluated like any other development intervention. Soft systems methodology has its principles like TQM, and, like TQM, a prescriptive approach can be taken but this is one which can contradict the principles. I also note that theories would be used to help the actors understand their own dynamics: the same comments could be made about the validity of theories in relation to the organisation in question. The letter illustrates one of two perspectives: the “context-dependency” perspective which holds that each organisation and situation is unique. The “quality programme” which is implemented is like no other. Even if there is agreement amongst different parties that this programme is “a success”, the factors and conditions which accounted for this cannot be generalised to other organisations and programmes. Another perspective is that quality programmes are interventions to organisations which have elements in common which distinguishes them from other development interventions, and which can be assessed for their effectiveness. Further, that generalisations can be made across organisations about factors which are needed for an effective programme.
The approach we took in our paper is a third which lies between these two caricatures: quality programmes are different in the details of their implementation but they follow similar principles. Particular types of programmes can be identified and are sufficiently similar to be classified as the same type of organisational intervention. A key issue is whether there are certain elements of a programme which are essential to success in most situation. Organisations are different, with different histories, cultures and internal power struggles. But comparable organisations can be found in comparable envrionments. If they introduce similar quality programmes, then some knowledge can be generated about whether the programmes produce certain results and the conditions which appear to be associated with this. This knowledge can be useful to other organisations and to policy makers, and can be added to with other studies of other programmes and other organisations. Patterns may or may not emerge, but at this stage too little research has been undertaken to tell.
In general, I am in agreement with much of the letter, including the action research approach described, which I have also advocated (Øvretveit 2002).[2] However I would not agree with ceasing to plan quality programmes and to fund evaluations of them just because certain theories suggest that any standard type of intervention must fail, or that generalisations cannot be made. This should encourage enquiry, not close it down.
References
(1) Øvretveit, J and Gustafsson, D Evaluation of quality improvement programmes. Qual Saf Health Care 2002;11:270-275.
Øvretveit, J. Action Evaluation of Health Programmes and Change: A handbook for a user focused approach 2002. Oxford: Radcliffe Medical Press.
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Quality improvement programmes: time for a rethink?
Submit responseDear Editor
I read the paper by Ovretveit and Gustafsen with interest, as I believe that this is a neglected area. I found their paper admirably clear and concise, and I would agree with many of their points. However, I feel that they have neglected one important area.
In their discussion of the ways in which this kind of research could be improved, they discuss the need for empirically based explanatory theories about what helps and what hinders quality improvement programme implementation, and mention the theories of innovation adoption and diffusion as potential candidates under this heading. I would suggest that in looking for theories to aid understanding of observed phenomena it is also worth considering health care providers as organisations, and looking to the literature of organisational studies. Even the smallest primary care providers can be said to be organisations, employing considerable numbers of ancillary staff as well as doctors and nurses. This fact is often barely acknowledged in the literature relating to behavioural change in response to quality improvement programmes; if it is considered, authors tend to talk vaguely about the need to change “organisational culture”, without clearly defining what this might be[1,2] Whilst some authors define organisations in terms of making rational decisions in pursuit of goals,[3,4] others argue that the reality is much more complex than this, involving social interactions between organisation members, and often-incompatible goals.[5-7] Taking this approach, it can be seen that any attempt to implement a quality improvement programme will come up against the nature of the organisation in which implementation is to occur. Particularly, the nature of the social interactions taking place, the “accommodations” [5] that take place to allow the definition of a programme of organisational activity in the face of those incompatible goals, and the distribution of power within the organisation will all affect what happens. If we want to understand what is happening during the implementation of quality improvement programmes, research should therefore be directed at these factors, using the methodologies developed by those who have spent many years doing this kind of research in other fields.[8]
Personally, I would go further, and argue that given the complex nature of health care organisations, it is strange to assume that any kind of proscriptive “quality programme” will succeed in more than one site, and that it is somehow possible to derive sets of “essential conditions” that will ensure successful implementation. Rather than expending large sums on designing such programmes and evaluating them, may be the time has come to approach the problem differently. It should be possible to define sets of desirable outcomes, and give these to health care organisations. These organisations could then be enabled, using action research methodology, to work to understand their own internal dynamics, and in reaching that understanding, go on to make any changes necessary to reach the desirable outcomes. The resulting processes would not be uniform across providers, but if the desirable outcomes were achieved, this would not matter. This, of course, goes against the government’s stated aim that a patient’s experience of the health service should be the same all across the country. However, as others have argued,[9] this drive for uniformity cannot necessarily be defended in an increasingly plural world. Some authors [10,11] have described work that takes elements of this approach. The time has come to stop using ideas borrowed from the more formal sciences, looking for the quality improvement equivalent of a “new drug” that will somehow improve quality across many different contexts, and concentrate on understanding the uniqueness of health care organisations, allowing that “uniqueness” to become a strength.
References
(1) Halligan A and Donaldson L. Implementing clinical governance: turning vision into reality. British Medical Journal 2001; 322(7299):1413-1417.
(2) Marshall M et al. A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance. Br J Gen Pract 2002; 52(481):641-5.
(3) Chandler AD. Managerial hierarchies. Organization theory: selected writings, Pugh DS (Ed). 1984, Penguin Books: London. Pp.95-123.
(4) Simon HA. Decision making and organizational design. In Organization theory: selected writings, Pugh DS (Ed). 1984, Penguin Books: London. Pp. 202-223.
(5) Checkland PB. Information, systems and information systems. 1998, Chichester: John Wiley.
(6) Vickers G. The art of judgement. 1995, Thousand Oaks: Sage.
(7) Weick KE. Sensemaking in organizations. 1995, Thousand Oaks, Ca.: Sage.
(8) Checkland PB and Scholes J. Soft systems methodology in action. 1999, Chichester: Wiley.
(9) Loughlin M. 'Quality' and 'excellence': meaning versus rhetoric. In NICE, CHI and the NHS reforms: enabling excellence or imposing control? Miles A, Hampton JR and Hurwitz B. (Eds). 2000, Aesculapius Medical Press: London.
(10) Atkins EM, Duffy MC and Bain DJ. The practice characterization model: the importance of organizational life cycles and targeted interventions in general medical practice. International Journal of Health Planning & Management 2001; 16(2):125-38.
(11) Cretin, S., et al., Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design. Medical Care 2001; 39(8 Suppl 2):II70-84.
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