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The Logics of Healthcare - In Quality Improvement Work
University of Skövde, Enterprises for the Future. University of Skövde, School of Business. (Medarbetarskap och Organisatorisk resiliens (FORE))ORCID iD: 0000-0003-2476-4411
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Quality improvement (QI) has become a cornerstone in contemporary healthcare organizations with the aim of enabling management that facilitates efficiency and effectiveness, while providing a consistent correlation between health spending and indicators of access to and quality of care. However, despite years of reform which have attempted to change healthcare professionals’ practice, traditional professional modes of working remain relatively stable and entrenched. Previous research has highlighted the fact that healthcare professionals’ active involvement in quality improvement work (QIW) is often lacking. Such a lack is often explained by professionals’ scepticism towards management, managers, and organizationally related improvement initiatives.  Yet, there is a shortage of studies which focus on analysis at the level of the actor when studying healthcare professionals’ involvement in QIW.

This dissertation presents a qualitative case study of the QIW undertaken by a multi-professional diabetes care team. It enables a description and analysis of healthcare professionals’ involvement in QIW at the actor level of analysis. A theoretical framework, consisting of the combination of institutional logics and institutional work, is applied in order to focus on varied and complementary aspects of institutional dynamics while simultaneously emphasizing the embeddedness of actors’ actions and interactions.

The study shows that healthcare professionals’ identification with and adherence to the professional logic in general impairs their involvement in QIW. Adherence entails perceiving professional judgments and discretion as legitimate in guiding practice and work. However, the study emphasizes that adherence to the professional logic varies amongst professionals representing different professions. This means that healthcare professionals’ acceptance of the bureaucratic control of work as legitimate differs - enabling diverse approaches and practices in QIW. Furthermore, the study illustrates that the physicians’ relative dominance hinders the utilization of multiple perspectives in the multi-professional team. This finding elucidates how dominance and hierarchization of logics enable healthcare professionals’ practice to remain relatively stable, despite managerial attempts to change and alter it. Finally, the study delineates the interactions needed in order to bridge institutional logics at the actor level of analysis. Such interactions are characterized by reciprocal acts of claiming and granting influence that constitute creative/disruptive institutional work, enabling actors to find new approaches to each other and further facilitate healthcare professionals’ involvement in QIW.

Place, publisher, year, edition, pages
Göteborgs universitet, 2017.
Keyword [en]
quality improvement, quality improvement work, healthcare organizations, healthcare professionals, institutional logics, institutional work
National Category
Business Administration
Research subject
Followership and Organizational Resilience
Identifiers
URN: urn:nbn:se:his:diva-13418ISBN: 978-91-628-9953-0 (print)ISBN: 978-91-628-9954-7 (electronic)OAI: oai:DiVA.org:his-13418DiVA: diva2:1083644
Note

Paper I Gadolin, C. & Andersson, T. Healthcare Quality Improvement Work: A Professional Employee Perspective, Accepted for publication in International Journal of Health Care Quality Assurance. Paper II Gadolin, C. Professional Employees’ Strategic Employment of the Managerial Logic in Healthcare, Conditionally accepted for publication in Qualitative Research in Organizations and Management: An International Journal. Paper III Gadolin, C. & Wikström, E. (2016) Organising Healthcare with Multi-professional Teams: Activity Coordination as a Logistical Flow, Scandinavian Journal of Public Administration, 20(4), pp. 53-72. Paper IV Andersson, T. & Gadolin, C. Institutional Work Through Interaction in Highly Institutionalized Settings: Quality Improvement Work in Healthcare, In review for Organization Studies.

Available from: 2017-04-12 Created: 2017-03-21 Last updated: 2017-06-05Bibliographically approved
List of papers
1. Organising Healthcare with Multi-Professional Teams: Activity Coordination as a Logistical Flow
Open this publication in new window or tab >>Organising Healthcare with Multi-Professional Teams: Activity Coordination as a Logistical Flow
2016 (English)In: Offentlig Förvaltning. Scandinavian Journal of Public Administration, ISSN 2000-8058, E-ISSN 2001-3310, Vol. 20, no 4, 53-72 p.Article in journal (Refereed) Published
Abstract [en]

Multi-professional teams are now common when organising healthcare. Such teams areconsidered to resolve fragmentation issues amongst units and their functions, facilitateefficient and high quality care and are also deemed to enable different professions to meetand exchange experience and knowledge. The expected consequence is superior decisionsand improved care. However, research suggests that the deployment of multi-professionalteams within healthcare organisations is problematic with regard to knowledge sharingand integration between different professional groups. While often recognised, the reasonfor this shortcoming has rarely been explored in depth. This study consequently elaborateson the factors hindering knowledge sharing through illustrating and discussing thelogics of different professional groups and the ensuing consequences when multiprofessionalteams interact. The finding is that the teams are being utilised by the medicalprofessions in accordance with their professional logic. This results in the coordination ofactivities, incorporating the patient flow logistics amongst the different professions; makingthe impact of multi-professional teams concrete in practice and illustrating their potentialpositive outcomes for professionals and patients, even though they are not operatingas forums for overt knowledge integration for the different professions.

Place, publisher, year, edition, pages
Göteborgs universitet, 2016
Keyword
Multi-professional teams, Organising healthcare, Coordination of activities, Logistical flow, Professional logics
National Category
Business Administration
Research subject
Humanities and Social sciences
Identifiers
urn:nbn:se:his:diva-12441 (URN)
Available from: 2016-06-13 Created: 2016-06-13 Last updated: 2017-04-12Bibliographically approved
2. Healthcare quality improvement work: a professional employee perspective
Open this publication in new window or tab >>Healthcare quality improvement work: a professional employee perspective
2017 (English)In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 30, no 5, 410-423 p.Article in journal (Refereed) Published
Abstract [en]

Purpose

The purpose of this paper is to describe and analyze conditions that influence how employees engage in healthcare quality improvement (QI) work.

Design/methodology/approach

Qualitative case study based on interviews (n=27) and observations (n=10).

Findings

The main conditions that influence how employees engage in healthcare QI work are professions, work structures and working relationships. These conditions can both prevent and facilitate healthcare QI. Professions and work structures may cement existing institutional logics and thus prevent employees from engaging in healthcare QI work. However, attempts to align QI with professional logics, together with work structures that empower employees, can make these conditions increase employee engagement, which can be accomplished through positive working relationships that foster institutional work, which bridge different competing institutional logics, making it possible to overcome barriers that professions and work structures may constitute.

Practical implications

Understanding the conditions that influence how employees engage in healthcare QI work will make initiatives more likely to succeed.

Originality/value

Healthcare QI has mainly been studied from an implementer perspective, and employees have either been neglected or seen as passive resisters. Weak employee perspectives make healthcare QI research incomplete. In our research, healthcare QI work is studied closely at the actor level to understand healthcare QI from an employee perspective.

Keyword
Relationships, Employee engagement, Quality improvement, Institutional logics, Professions, Work structure
National Category
Business Administration
Research subject
Followership and Organizational Resilience
Identifiers
urn:nbn:se:his:diva-13626 (URN)10.1108/IJHCQA-02-2016-0013 (DOI)000404784700002 ()28574326 (PubMedID)2-s2.0-85020192774 (Scopus ID)
Projects
Förutsättningar för vårdutveckling - ett medarbetarperspektiv
Funder
AFA Insurance, 110159
Available from: 2017-06-05 Created: 2017-06-05 Last updated: 2017-08-08Bibliographically approved

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