Why adopt ISO 9001 certification in hospitals? A case study of external triggers and sensemaking in an emergency department in Norway

Abstract

Background: Certification and accreditation are widely used to achieve quality and safety in health care but are also questioned regarding their assumed effects. This is a challenge for policymakers and managers, since adoption of these regimes can have a circumstantial impact upon organizations. This study's aim was to explore how external conditions catalyzed and triggered organizational change and internal sensemaking processes as part of an ISO 9001 certification process. Methods: The study applied an explanatory single-case design, using a narrative approach, to retrospectively follow a sensemaking process in an emergency department in a Norwegian hospital undergoing ISO 9001 certification. The certification process was a pilot initiated by a Regional Health Authority, which ran from autumn 2008 until spring 2012. Nine semi-structured, qualitative interviews were conducted, and documents in the form of minutes and reports were collected. The data was analyzed according to an organized sensemaking framework. Results: The adoption of the ISO 9001 certification did not follow a comprehensive decision-making process. Our study shows two external situational triggers that initiated adoption. First, a countrywide supervision conducted by the Norwegian Board of Health Supervision concluded that inadequate management and leadership negatively affected the day-to-day running of Norwegian emergency departments. This external disruption visualized longstanding organizational challenges that threatened the managers' shared identity. A search for meaning became prominent. Second, an occasional, externally initiated certification project was a plausible solution that would lead to an immediate action that would reduce uncertainty. Institutional requirements and concepts in the international ISO 9001 standard and in the national health regulations were unfamiliar and ambiguous for the project group involved in the certification. These issues became the institutional external triggers for intra-organizational sensemaking processes that made ISO certification possible. External assessments were acknowledged as useful for making improvements.

Certification as support for resilience? Behind the curtains of a certification body — a qualitative study

“…Further, the auditing practices inside hospital departments showed examples of the possibilities the auditors had to uncover challenges or opportunities for improvement of daily activity. Such practices can give surprises or external disruptions leading hospitals to trigger resilience by activating internal collective sensemaking processes and purposeful reorganizing [46][47][48].…”

“…We also found that auditors empowered local improvement initiatives at the sharp end. A holistic approach to auditing has been shown to be important for internal motivation and commitment to auditing practice and improvement work [18,48]. The potential to learn is also exposed when auditors take initiatives to transfer experiences and good practices from one auditee to another, within or between organizational fields.…”

Comparison of external evaluation policies and regulations for quality improvement and safety of health services in Norway and the United States

“…According to recent studies there is an ongoing turning point in the context of accreditation: moving from a culture of means towards evaluation of results, addressing the organizational core (Brubakk et al. , 2015; Johannesen and Wiig, 2017; Johannesen et al. , 2020; Johannesen, 2020).…”

Impact of ISO standard application on financial performance of private hospitals

“…For the purposes of our paper, the analysis of the impact of the application of ISO standards on financial performance in private hospitals, we selected the following papers. Johannesen et al [8] pointed out the reasons for the application of ISO standards in hospitals (such as Norway). Chaw et al [3] identify key differences in quality management between accredited hospitals, i.e.…”

“…By adhering to the standard, health institutions improve the efficiency of a management system and thus strengthen the trust that their patients have in their system [24]. By certifying the management system, health institutions can show their readiness to consistently comply with all the requirements of the standard aiming to constantly improve patient satisfaction which is reflected in improving their health by providing quality health care [8]. Health is a basic human right and one of the most important prerequisites for economic development and quality life of inhabitants of a country [14, p. 168].…”