Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service

Abstract

BackgroundHealthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.MethodsWe conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents.ResultsTwo organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of ‘slack’—expressed by participants as the ‘space to think’ and ‘someone to do the doing’—and the presence of a functioning board.ConclusionsUnderperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

Engaging with theory: from theoretically informed to theoretically informative improvement research

“…However, they do not stop here, but position their study theoretically as a case of ‘corruption of managerial techniques’, a notion first introduced by Lozeau et al 15. Jones and colleagues13 make a theoretical claim that the diversity of QI outcomes can be explained by different ways of closing the ‘compatibility gap’ between the assumptions underpinning the proposed board-level intervention (eg, an assumption that there is a functional board) and the characteristics of the adopting organisation (eg, the actual configuration of the board). An examination of this claim sets in motion a fruitful dialogue between the theoretical and the empirical.…”

“…This approach implies a dialogue between the theoretical and the empirical, whereby the researcher uses a particular case or set of cases as an opportunity for further refining previous conceptualisations of the general processes contained in the earlier theoretical accounts 12. I will use the Jones et al 13 paper in this issue as an example of successfully deployed theoretically informative approach, highlighting some practical tips for researchers who aspire to move from merely applying theory towards entering into dialogue with it and, through doing so, refining its assumptions.…”

“…First, it is important to find a balance between the empirical question ‘What is going on here?’ and the theoretical question ‘What is this a case of?’ 12 Jones et al 13 make it clear at the outset that they aim to understand ‘the response of healthcare provider organisations to a board-level QI intervention’, which involved the use of a research-based guide for senior hospital leaders to develop and implement organisation-wide QI strategies 14. This sets their study in a novel empirical context.…”

“…Since theorising is an iterative and recursive process,12 16 it is important to consider previous empirical studies building on the relevant theory rather than solely rely on the original theoretical account 16. Whether the theoretical approach is chosen prospectively (prior to data collection) or retrospectively (at the data analysis stage, as is the case in the Jones et al 13 paper), this enables the researcher to paint the state-of-the art picture of what is already known, identify gaps in theoretical knowledge and, subsequently, focus on addressing them. Not only do Jones et al 13 draw on the original Lozeau et al 15 paper, they also find valuable insights in subsequent studies exploring the distortion of managerial techniques in organisations.…”

“…Whether the theoretical approach is chosen prospectively (prior to data collection) or retrospectively (at the data analysis stage, as is the case in the Jones et al 13 paper), this enables the researcher to paint the state-of-the art picture of what is already known, identify gaps in theoretical knowledge and, subsequently, focus on addressing them. Not only do Jones et al 13 draw on the original Lozeau et al 15 paper, they also find valuable insights in subsequent studies exploring the distortion of managerial techniques in organisations. For instance, they engage with such ideas as the possibility of top-down distortion described by Addicott et al 17 in their study of healthcare networks and the erosion of staff engagement over time highlighted by Kislov et al 18 in their longitudinal study of facilitation in a collaborative research partnership 18…”