Abstract
Objective
To examine the projects of professionalisation and institutionalisation forming health care professions’ engagement in quality improvement collaborative (QIC) implementation in Denmark, and to analyse the synergies and tensions between the two projects given the opportunities afforded by the QICs.
Methods
This was a cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark involving 23 individual interviews and focus group discussions with 75 people representing different professional groups. We conducted a reflexive thematic analysis of the data, drawing on institutional contributions to organisational studies of professions.
Results
Study participants engaged widely in QIC implementation. This engagement was formed by a constructive interplay between the professions’ projects of professionalisation and institutionalisation, with only few tensions identified. The project of professionalisation relates to a self-oriented agenda of contributing professional expertise and promoting professional recognition and development, while the project of institutionalisation focuses on improving health care processes and outcomes and advancing quality improvement. Both projects were largely similar across professional groups. The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing and delivering high-quality patient care.
Conclusions
Future strategies for QIC implementation should position QICs as a framework that promotes the integration of professions’ projects of professionalisation and institutionalisation to successfully engage professionals in the implementation process, and thereby optimise the effectiveness of QICs in health care.
Keywords: quality improvement collaboratives, healthcare professions, implementation
Introduction
The purposeful and sustained engagement of health care professionals in quality improvement (QI) initiatives is widely acknowledged as a critical determinant for their success, and there has been an increase in bottom-up QI approaches allowing health care professionals to set agendas and drive implementation.1–4 One such model is the quality improvement collaborative (QIC) where teams of health care professionals share methods, ideas, and data within and across teams to improve health care processes and outcomes for a targeted area of care.5–7
Studies of QIC consistently note that health care professionals’ engagement is a critical contributor to QIC implementation and outcomes,5,6,8,9 although the nature of professionals’ engagement and how to facilitate it has only recently been explored in further depth.5,8,10,11 This literature has shown that professionals are less likely to engage in QICs when they perceive them as a bureaucratic intrusion into their professional work and not relevant to their interests. 10 Also, health care professionals developed their skills in health care improvement when they perceived an alignment between their motivations and the organisational structures of and resources for the QIC initiative. 5 These insights are mirrored in the broader literature on health care professionals’ engagement in QI, and the ways in which it can be facilitated by policymakers, managers and administrators.12–15 In a study of Lean implementation in health care, Fournier et al. 14 attributed physician resistance to tensions between lean systems-thinking and their medical professional logic. They recommended that policymakers position Lean as a framework that promotes the integration of managerial and medical priorities centred around patients’ needs to optimise outcomes. Health care professional engagement was demonstrated in large-scale QI programmes whereby strategic efforts were made to integrate professional and managerial priorities in the framing of the initiative. 15
These observations suggest that health care professionals’ engagement in QIC implementation requires alignment between the managerial logics of the intervention and the professionals’ own professional logics. However, there is a need for further empirical research that explores what constitutes professional and managerial logics within QICs and how the framing of and opportunities afforded by QICs enable a constructive interplay between these logics. This study aims to contribute to filling this gap. We drew on institutional theory which has conceptualised these logics as projects of professionalisation and institutionalisation. It offers an analytical perspective for understanding the interplay between professional and managerial logics in professions’ engagement in the institutional change process of QIC implementation.16,17 The aim of the paper was to examine the projects of professionalisation and institutionalisation forming health care professions’ engagement in QIC implementation attending to similarities and differences across different professional groups and QICs. Furthermore, we analysed the synergies and tensions between the two projects given the framing of and opportunities afforded by the QICs.
Our focus was the use of QICs within a Danish national health care quality programme launched in 2015. The QICs sought to address dissatisfaction among health care professionals regarding substantial bureaucracy and limited freedom of action in prior QI work. 18 The QICs represented a turning point in the approach to QI by introducing a bottom-up approach where health care professionals were responsible for setting agendas and driving the implementation process. 18
Theoretical framework: projects of professionalisation and institutionalisation in QIC implementation
As noted, we drew on recent contributions to organisational studies of professions within institutional theory, which emphasise the influential role of professions in processes of institutional change.16,17,19 The theory proposes that institutional change, such as QIC implementation, is a complex social process comprised of multiple, interdependent and often overlapping ‘projects’ of professionalisation and institutionalisation.16,17 QIC implementation represents a project of professionalisation by providing an opportunity for health care professions to develop their professional practice and strengthen their status.16,17 In line with Muzio et al., our understanding of the concept of projects of professionalisation was informed by the neo-Weberian sociology of professions,17,20 which proposes that projects of professionalisation originate from the jurisdictions of the professions and are comprised of their self-oriented interests in promoting professional expertise and development and increasing status in relation to other professional groups.17,20
Quality improvement collaborative implementation also represents a project of institutionalisation, that is how health care professions make sense of and embed the political and organisational framing of the QICs, including policymakers’ and administrators’ aim to improve health care through evidence-based objectives, measures, and change initiatives, and a bottom-up and data-driven methodology, into their professional practices. Our analytical lens was informed by neo-institutional profession research, particularly Scott,17,19,21 whereby projects of institutionalisation capture the broader institutional role played by professions in defining, interpreting, and applying institutional elements. Scott identified three ways in which this role may be exercised. First, professions act as cultural-cognitive agents devising categories and frameworks that contribute to defining and framing issues. Second, professions act as normative agents by offering norms and standards to guide what individuals, groups, or organisations ‘should’ do in particular contexts. Third, professions act as regulatory agents by participating in the establishment and implementation of legally sanctionable rules and regulations.17,19,21 While the use of Scott’s framework is novel within QI research, it has been applied to account for projects of institutionalisation of professions within other areas of health care, for example, welfare governance in older people and integrated care. 10 In our analysis, we focused on the cultural-cognitive and normative aspects of the project of institutionalisation, as these were most relevant to our setting.
The proposed interdependence between the projects of professionalisation and institutionalisation in QIC implementation implies that rather than existing side by side, the projects interact, meaning that professions are important actors in institutional change. Thus, when the professions experience alignment among these projects, they will, together with policymakers and administrators, engage in implementing the QICs in their local contexts. In the analysis, when we explored the synergies and tensions between the professions’ projects of professionalisation and institutionalisation, it was with the expectation that integration between the projects positively influences the engagement of professions in QIC implementation.
Methods
The study was designed as a qualitative cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark (Box; see also Online Supplement Tables S1 and S2).
Box. Quality Improvement Collaboratives (QICs) in Denmark.
The Danish QICs were introduced as part of the Danish Health Care Quality Programme launched in 2015. QICs are organised at the national level and include local quality improvement teams (QI teams) from hospitals and municipalities (community care organisations) across the five Danish regions. Each QI team consists of staff representing different health care professions and, where relevant, departments and organisational units. A ‘typical’ QIC involves QI teams from 15 to 25 sites with 3–12 participants each, although there are exceptions. 18
QIC objectives, and outcome and process measures, are defined by a faculty of clinical experts within the targeted area. They are broadly formulated to provide space for QI teams to tailor improvement projects to their local contexts. 18 The Danish QICs are based on an adapted version of the Breakthrough Series Collaborative Model developed by the Institute for Healthcare Improvement.18,22 QI teams participate in national learning sessions about clinical best practices and improvement methods, and share experiences of making local changes. Between learning sessions, the teams implement improvement projects in their settings based on the tools and methods of the Model for Improvement and the qualitative assessment tool Model for Understanding Success in Quality (MUSIQ).23,24 The teams are supported by QI specialists, typically consultants from hospitals or municipal quality departments, who provide process facilitation, training in QIC methodology, and data to support progress assessment. QI specialists may be team members or external supporters. 18
Data collection
We used qualitative focus group interviews with teams from a QIC focusing on children with diabetes (QIC Diabetes) and a QIC on upper femur hip fractures among people aged 65 years and older (QIC Fractures) to capture the range of health care professions in QI teams. The QIC Diabetes teams mainly comprised of physicians and nurses, with some also including a social worker or psychologist. All professionals were from paediatric hospital wards. QI specialists provided external support (see Box). The QIC Fractures involved separate teams from hospitals and municipalities, with the former involving physicians, nurses, and physiotherapists from multiple clinical specialities and departments, with some also including an occupational therapist, while municipal teams included physiotherapists, nurses, and occupational therapists from different departments, and, in some cases, a health care worker. The QI specialists were part of the Fractures teams regardless of the context.
Data was collected between February and June 2020 for QIC Fractures, and between June 2021 and January 2022 for QIC Diabetes. We aimed to recruit 10 QI teams in each QIC from across the five Danish regions and from different hospitals (university hospitals and smaller hospitals) in QIC Diabetes, and from hospitals and municipalities in QIC Fractures, to capture geographical and organisational variation and to increase the analytic generalisability. 25 However, for QIC Diabetes it was only possible to include eight teams because of staff shortages and increased workloads during the COVID-19 pandemic. We thus conducted focus group interviews with 18 QI teams, each with 2–6 participants with mixed professional backgrounds, totalling 66 participants. We further conducted five interviews (three focus group interviews with 2–3 participants and two individual interviews, totalling nine participants) with QI specialists in QIC Diabetes to ensure comparability across QICs. Thus, 23 focus group and individual interviews with a total of 75 participants were conducted (see Online Supplement Table S3 for an overview of focus group and individual interviews).
Interviews were conducted using video (19 interviews) or in person at a location chosen by study participants (four interviews). They lasted 45–90 minutes and were all conducted by the first author, who is an experienced social scientist and not affiliated with the implementation of the QICs. Interviews used a semi-structured interview guide with open-ended questions. 25 The guide was informed by the theoretical framework and explored issues related to participants’ perceptions and experiences of the QIC implementation and its levers for professional development, how they viewed their role in the QIC, and what contributed to their engagement in the implementation process. All interviews were digitally recorded, transcribed verbatim, and anonymised.
Data analysis
Interviews were analysed using reflexive thematic analysis.26,27 The material was initially coded in two overall themes that included (1) projects of professionalisation and (2) projects of institutionalisation (first round of coding). During this first round of coding, the material was read and analysed using the theories of projects of professionalisation and institutionalisation to identify subthemes within each theme. Throughout this analysis, we systematically looked for similarities and differences between the professional groups involved in the QICs. A second round of coding involved rereading themes and subthemes and further analysis focussing on identifying potential synergies and tensions between the identified projects of professionalisation and institutionalisation. All transcripts were coded by the first author using NVivo 12 software, with preliminary results discussed among all authors. During analysis, themes and subthemes were investigated in relation to the full dataset while looking for discrepancies and disconfirming evidence before writing up the findings.
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki and approved by the Register of Public Research Projects in Central Denmark Region (file no. 1-16-02-285-19). The Central Denmark Region Committees on Health Research Ethics deemed our study not to be a health research study, according to the Consolidation Act on Research Ethics Review of Health Research Projects, Consolidation Act number 1083 of 15 September 2017 section 14, and thus, not requiring consideration by an ethics committee. Before all interviews, participants were informed about the study and written consent was obtained. In the analysis and presentation of the collected data, all QI teams and individual participants were anonymised.
Results
Figure 1 provides a thematic map of identified themes and subthemes. We first present findings regarding the projects of professionalisation and institutionalisation and their prospects for forming health care professions’ engagement in QIC implementation, followed by an analysis of the synergies between the projects given the framing of and opportunities afforded by the QICs. Throughout this section, health care professionals are referred to as professionals.
Figure 1.
Thematic map.
Projects of professionalisation and institutionalisation in QIC implementation across professions and QICs
QIC implementation as a project of professionalisation
Across professions, the professionals perceived the QICs as a strong project of professionalisation. A commonly articulated dimension of this project was a self-oriented interest in how the QIC afforded opportunities for professional expertise contributions. The nature of this expertise varied however. Some professionals described their interest in relation to how their expertise could inform the practices being targeted by the QIC. Most professionals valued the bottom-up approach of the QIC methodology as this provided levers for them to define the team’s local improvement projects informed by their professional knowledge. This professional expertise interest was particularly expressed in relation to their own professional jurisdictions but this focus did not contribute to interprofessional tensions.
Other professionals described their expertise contributions in relation to demarcating between different types of work, defining what fell within, and outside of, one’s perceived area of expertise. Several professionals distinguished between the clinical aspects of the improvement work and the methodological and administrative work of QIC implementation, which they considered to be outside of their professional expertise and of a lower priority. For example, a nurse in QIC Diabetes was less interested in QIC implementation work that was not related to her nursing background, which in her view should have been addressed by others on the QI team.
Generally, I engage my professional competencies in the QIC work. But some of my tasks are completely unrelated to my professional competencies. They ended up at my desk because no one else in the team handled them. (...) So I was a bit annoyed by that whole process. (Nurse, QIC Diabetes)
The perceived division between the clinical – and in most cases mono-professional – aspects of improvement work and the methodological and administrative work, points to the need to ensure a clear linkage between these to provide the best conditions for engaging health care professionals in implementation.
Another dimension of the project of professionalisation was the opportunities that the QICs provided for professional recognition. There were some differences between professional groups in how they spoke about professional recognition. Nurses, therapists, and community health care workers valued being acknowledged as an important resource for improving care quality. Being part of a national, politically prioritised improvement project was an important aspect of that recognition. For some physicians, professional recognition was linked to the experienced (lower) hierarchical ranking of their clinical speciality in comparison to other medical specialities, and the possibilities that the QIC provided for changing their status. For example, some physicians in QIC Fractures explained how the QIC had revitalised their medical speciality into a highly prioritised one. In both cases, feeling professionally recognised spoke to the professionals’ self-oriented interest in increasing their professional status, which promoted their engagement in QIC implementation.
A third and final dimension of the QICs as a project of professionalisation was the possibilities it offered for professional development. Across professional groups, several participants described the ways that the QIC provided space and evidence to reconsider and improve their professional practices, as articulated by a physiotherapist in QIC Fractures.
It’s super cool that the QIC has provided us with insights based on the newest research and evidence that we can use to develop our practice to the benefit of our patients. That is motivating to me, and I think it is important to all physiotherapists. (Municipal physiotherapist, QIC Fractures)
The experience of the QIC as an opportunity for professional development was facilitated by the broad scope of the QICs and ability to locally define the team’s improvement projects. These conditions generally created space for the different professional groups to simultaneously pursue their mono-professional interests in professional development. However, some participants, particularly those in QIC Fractures municipal teams, did not share this experience. For example, a municipal nurse thought that the QIC’s targeted focus on hip fracture patients limited its relevance for their municipal context.
It has been a real challenge that the QIC only involves hip fracture patients. It’s hard in a municipal setting to allocate so many resources to just one diagnosis. Had it been all medical surgical patients then maybe…, but it is hard. We must treat all diagnoses, you know. (Municipal nurse, QIC Fractures)
For some participants, the lack of opportunities for professional development led to a decreasing engagement in QIC implementation, causing interprofessional tensions and challenging the progress of the QIC work in some teams, while others adjusted the QIC focus areas and/or target group to better align with the professional ambitions of all professions (e.g. involve other groups of patients with similar needs), thereby increasing all team members’ engagement in the QIC. These experiences highlight the challenges of keeping all professional groups engaged in complex QICs that involve multiple sectors and professions, as the focus areas and target groups will inevitably speak more to some than others. Moreover, the adjustment practices of some QI teams highlight the professionals’ active agency in QIC implementation, but also point to a need for awareness of the potential negative consequences that adjustments may have for the QIC outcomes.
QIC implementation as a project of institutionalisation
To all participants, the QICs also represented a project of institutionalisation. One dimension of this project that engaged professionals was the managerial and political priority and formal goal behind the QICs to improve health care processes and care outcomes for patients.
Something that drives me in this work [QIC implementation], is that I’m able to improve the care for my patients. I’m a clinician with a capital C, so I find it crucial for my engagement that our work makes a difference for my patients. (Physician, QIC Diabetes)
Professionals’ use of the QIC as a framework for working towards high quality health care processes and patient outcomes demonstrates their role as cultural-cognitive institutional agents in setting strong cultural standards for their organisations.
Professional groups differed in their interpretations of high-quality health care processes and outcomes. For example, physicians tended to emphasise quantifiable patient outcomes, such as lowering average blood sugar levels among children with diabetes. In contrast, nurses and psychologists discussed how the QIC contributed to improving patients’ experiences of care. These differences generally did not lead to interprofessional tensions as the breadth of the QIC objectives allowed for different professional priorities to coexist. However, within QIC Fractures there were a few examples of intraprofessional tensions between physicians from different clinical specialities. These tensions revolved around different understandings of how to most appropriately improve the care of hip fracture patients.
You have several very different specialities that must collaborate on the project, and they have to agree on the goals, change initiatives, and how to run the QIC work to achieve the best results. That led to some tensions at the beginning of the implementation. But luckily, we share a passion for the patient group, so we ended up finding a joint way. (Physician, QIC Fractures)
While these initial tensions did not lead to QIC implementation challenges, they point to the potential challenges of misaligned understandings when professionals with different professional backgrounds need to collaborate on implementing the QICs, particularly in complex organisational settings such as QIC Fractures spanning different sectors and professions.
A further dimension of the project of institutionalisation was the opportunities for improvements in interprofessional and intersectoral collaboration provided by the QIC. Participants’ descriptions reflected how they used the QICs as a cultural-cognitive framework for establishing optimal conditions for collaboration across professional and sectoral boundaries. The multiprofessional composition of the QI teams provided a formalised space for interaction between professionals with different backgrounds and organisational positioning. Several study participants highlighted how these interactions had led to increased familiarity and fewer prejudices across professional boundaries that were conducive to interprofessional collaboration. Also, QICs were seen as an opportunity to clarify the division of labour between different professional groups, departments, and sectors, which led to better work processes and more holistic understandings of patient care pathways. The new opportunities for interprofessional collaboration were particularly pronounced in QIC Fractures where the composition of professions and departments was more varied, and participants had limited prior knowledge about each other.
A third and final dimension of the QICs as a project of institutionalisation concerned opportunities for advancing quality improvement methodology. Across professional groups, there was an emphasis on the small-scale-oriented methodology that the majority of participants perceived as advancing the QI approach. They used the QIC to provide a new set of norms and standards for the development of relevant and efficient QI projects, thereby acting as normative institutional agents. In particular, the idea of iteratively testing changes on a small scale using Plan-Do-Study-Act cycles before scaling up was seen to be a meaningful and efficient QI approach, leading to faster improvements of higher quality.
The small-scale thinking is really meaningful. It allows room for trying things out, adjusting continuously with a focus on what makes sense for us and our patients. (…) You know instead of these large research projects where you have to follow rigid protocols that don’t even work but ‘that was how the project was designed.’ (Physician, QIC Diabetes)
Synergies between projects of professionalisation and institutionalisation in QIC implementation
Our findings show that professions were highly engaged in QIC implementation and that their engagement rested on projects of both professionalisation and institutionalisation. Across professional groups, the two projects generally demonstrated a high level of integration. We identified three factors as integrating links: the bottom-up approach to implementation, the participation of QI specialists, and the desire to develop and deliver high-quality patient care (Figure 1).
The bottom-up approach comprised the deliberate broad formulation of QIC objectives and measurements and the consequent ability for the QI teams to define and implement projects tailored to their local contexts. It also allowed for the QI teams to adjust the QIC methodology and use additional methods and tools already in use in their local context. The bottom-up approach provided a lever for professions’ project of professionalisation, as by defining their local improvement projects they were able to contribute with their professional expertise and engage in professional development. In relation to the project of institutionalisation, the bottom-up approach supported the political intentions of the QICs to make health care professionals responsible for setting quality agendas and taking a lead on QI. As noted above, our findings demonstrate that the professionals responded positively to these ‘bottom-up’ intentions and actively engaged with them. In this way, the project of institutionalisation became interlinked with the project of professionalisation. However, in some cases, the institutional framing of the QIC objectives was considered too narrow to correspond with certain professions’ self-interested project of professional development, causing tension and decreasing engagement in QIC implementation as noted above. Thus, although the bottom-up approach can be seen as a strong enabling factor for integrating the projects of professionalisation and institutionalisation, the cases showed that it requires leadership support.
The participation of QI specialists as facilitators of the QI teams’ improvement work was identified as a further integrating factor. Although there was variation, QI facilitation involved overseeing the implementation process; planning, facilitating, and following up on team meetings; and providing methodological support. Study participants highly valued the involvement of the QI specialists in their improvement work, emphasising their methodological and administrative QIC responsibilities and expertise, which most participants considered to be outside of their own professional expertise and less relevant for their professional development. Thus, QI specialists became a key part of the professions’ experience of QIC implementation as enabling their project of professionalisation. The QI specialists also constituted an integratal part of the project of institutionalisation, as they were seen as key actors in the organisational setup of the QICs as facilitators of the local QIC work, which proved to be important for supporting the engagement of the professionals. In some cases QI specialists became independent actors in QIC implementation, viewing their primary role as filling gaps between projects of professionalisation and institutionalisation and easing tensions by undertaking ‘grey zone’ tasks essential to advancing QIC work.
Finally, the projects of professionalisation and institutionalisation were both permeated with an agenda for developing and delivering high-quality patient care. Study participants expressed a deep interest in patients and improving health care processes and care outcomes. Their project of professionalisation, involving interests in professional development, recognition and expertise contributions, was clearly connected to a desire to contribute to developing best patient care. Likewise, delivering high-quality patient care constituted a cornerstone of the project of institutionalisation of the QICs. The organisational and methodological framing of the QICs involving small-scale improvements and locally defined, practice-oriented improvement intitiatives, tied the project of institutionalisation even closer to the development of high-quality patient care.
Discussion
This study found that professionals engaged widely in the implementation of two national QICs in Denmark. Our theoretical point of departure within the institutional, organisational studies of professions, helped specify how this engagement was formed by a constructive interplay between the professions’ projects of professionalisation and institutionalisation. Our findings add to evidence of other work within the QI literature, pointing to the importance of promoting integration between managerial and professional logics in the framing of QI interventions to successfully engage professionals in the implementation process.13–15
We found only a small number of instances of tensions between professions’ projects of professionalisation and institutionalisation. These concerned an experienced clash between the methodological and administrative work required by the QICs and the types of work that many professions considered within their area of mono-professional expertise. Tensions also related to the framing of the QIC target group and focus area, which were perceived as too narrow by some and not corresponding with their self-interested project of professional development. In line with Fournier et al., 14 the professionals in our study consistently linked the experienced tensions between the projects to a decreasing engagement in QIC implementation, which challenged the progress of the QIC work.
Our study identified only small differences between the projects across different professional groups. Differences were apparent in how the QIC implementation was seen to contribute to professional recognition, provide opportunities for professional development and expertise contributions, and improve health care processes and care outcomes. There were only few instances where these professional differences raised intra- or interprofessional tensions and ultimately decreased engagement among those who experienced these tensions. This is consistent with other work that has reported differences in health care professionals’ support of QIC implementation processes and implementation of similar QI interventions according to professional backgrounds, expectations, interests, and status.2,8,13–15,28
We found the two projects of professionalisation and institutionalisation generally to be highly integrated, and largely similar across professional groups, and we suggest that three factors afforded by the QIC framework promote this integration between the projects. The first is the bottom-up approach embedded in the QIC framework, which proved to be key for the integration of the projects and therefore for the professions’ engagement in QIC implementation. This finding aligns with the wider QI literature reporting a positive association between bottom-up QI and professional engagement.6,7,11–14 For example, Shaikh et al. found that involvement in the selection of QI problems and the development of improvement initiatives were key enablers of clinical engagement in QI implementation. 12 Our study adds nuance by demonstrating how the broad framing of the QICs allowed different professional groups within the same QI team to simultaneously pursue different projects of professionalisation and institutionalisation. Thus, besides contributing positively to professional engagement, the bottom-up approach may resolve potential interprofessional tensions in QIC implementation. However, elsewhere we showed that locally provided flexibility to adjust QIC content and methodology can at times result in radical translations of the QIC intervention, which, while positively affecting professional engagement and inter-professional collaboration in QIC implementation, might undermine the achievement of QIC outcomes. 29
A second factor was the role of QI specialists, and their active agency in filling gaps and bridging tensions between the professions’ projects of professionalisation and institutionalisation. The role of QI specialists has been discussed in the QIC and wider QI literature, with some noting difficulties for professionals to accept the involvement of specialists because they represent knowledge that professionals perceived as irrelevant and unscientific. 2 Others, in alignment with our results, found that QI specialists empowered QI teams to take ownership of change and supported them in advancing their local QIC work.6,8,29 Our findings regarding the specifics of how QI specialists act as integrators of professions’ projects of professionalisation and institutionalisation in QIC implementation add an important and novel nuance to these existing studies.
There remain questions around the role of QI specialists as integrators with regard to the sustainability of QIC outcomes and methodology, when the QIC project, and therefore QI specialist support, ends. This may be particularly relevant in situations where specialists support integration by ‘stepping in’ rather than facilitating professions’ embracing aspects of QIC implementation that they did not initially experience as corresponding to their projects of professionalisation and institutionalisation.
A third factor was the strong focus on the high-quality patient care, which is at the core of the QIC approach and was realised through broad objectives, small-scale improvements, and locally defined, practice-oriented improvement initiatives. This focus supports the thorough and critical engagement of health professionals in QI that achieves outcomes that matter to them, that is improved patient outcomes. 30 The high-quality patient care focus embedded in the QICs thus becomes a successful integrator of the projects.
Strengths and limitations
A key strength of this study was the large and diverse sample of health care professionals involved in QIC implementation. It is likely that the results may be transferable to organisational contexts that are similar to those within the Danish health care quality programme. We have provided detailed information about the QICs and their specific context to make it possible for readers to assess the relevance and applicability of the results to their own context. Study participants were interviewed in interprofessional focus groups, providing opportunity for exploring the diversity and dynamics of different professions’ engagement in QIC implementation. At the same time, the group setting may have prevented participants to express other, perhaps more sensitive, perspectives, including professional differences and tensions. Finally, the analysis was based on data from qualitative interviews. On reflection, triangulating the interview data with data from longer term fieldwork in the clinical setting would have been a valuable contribution to the study, both in informing the interview guide and in contextualising the findings from the interviews.
Implications for practice
Our study may inform future planning and implementation of QICs. We show that to successfully engage professionals in implementation, and thereby promote more effective use of QICs in health care, future strategies should position QICs as a framework that promotes the integration of professions’ projects of professionalisation and institutionalisation. It is important, in the planning and implementation of QICs, to emphasise a bottom-up approach to QI, by providing autonomy to QI teams to define and implement their local QI projects. We identified QI specialists as key actors in QIC implementation, and QICs should consider granting them sufficient opportunity to help the professions integrate their projects. Finally, a focus on improving patient care was found to be a key factor in helping professionals take responsibility for implementation, which may be especially relevant for complex organisational settings spanning different sectors and professions, as a means to reduce potential tension between professional groups. Attention should be paid to the potential negative impacts on sustainability and translation of QICs where a bottom-up approach and participation of QI specialists are key to successful implementation.
Conclusion
This study suggests that successful engagement of professionals in the implementation of QICs, and therefore promotion of more effective use of QICs in health care, is facilitated by effective integration of the professions’ projects of professionalisation and institutionalisation. Our findings add to the current body of QIC literature concerning health care professionals’ engagement in QIC implementation by providing in-depth insights into the nature of the engagement of different professional groups and how to facilitate this engagement. There is a need for future research to further investigate the link between the integrating factors and the outcomes and sustainability of the QIC work.
Supplemental Material
Supplemental Material for Engaging health care professionals in quality improvement: A qualitative study exploring the synergies between projects of professionalisation and institutionalisation in quality improvement collaborative implementation in Denmark by Kathrine Carstensen, Joanne Goldman, Anne Mette Kjeldsen, Stina Lou, and Camilla Palmhøj Nielsen in Journal of Health Services Research & Policy.
Acknowledgements
We would like to thank all the health care professionals who took time to participate in an interview. We would also like to thank the national project managers and the regional coordinators of the two QICs who helped to recruit interview participants for this study and provided valuable feedback on our emerging findings.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Health Research Fund of Central Denmark Region (DK) (Grant number A2075), DEFACTUM, Central Denmark Region (DK), and Aarhus University, Graduate School of Health Sciences (DK).
Supplemental Material: Supplemental material for this article is available online.
Ethical statement
Ethical approval
The study was approved by the Register of Public Research Projects in Central Denmark Region (file no. 1-16-02-285-19). The Central Denmark Region Committees on Health Research Ethics assessed our study to not require further consideration by an ethics committee.
ORCID iDs
Kathrine Carstensen https://orcid.org/0000-0002-4999-1314
Joanne Goldman https://orcid.org/0000-0003-1589-4070
Anne Mette Kjeldsen https://orcid.org/0000-0003-0787-0351
Stina Lou https://orcid.org/0000-0001-6177-5780
Camilla Palmhøj Nielsen https://orcid.org/0000-0001-9199-3463
References
- 1.White M, Butterworth T, Wells JSG. Healthcare quality improvement and ‘work engagement’; concluding results from a national, longitudinal, cross-sectional study of the ‘productive ward-releasing time to care’ programme. BMC Health Serv Res 2017; 17: 510. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gadolin C, Andersson T. Healthcare quality improvement work: a professional employee perspective. Int J Health Care Qual Assur 2017; 30: 410. [DOI] [PubMed] [Google Scholar]
- 3.Dixon-Woods M. How to improve healthcare improvement—an essay. BMJ 2019; 366: l5514. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Baker U, Petro A, Marchant T, et al. Health workers’ experiences of collaborative quality improvement for maternal and newborn care in rural tanzanian health facilities: a process evaluation using the integrated ’promoting action on research implementation in health services’ framework. PLoS One 2019; 13: e0209092. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.De la Perrelle L, Cations M, Barbery G, et al. How, why and under what circumstances does a quality improvement collaborative build knowledge and skills in clinicians working with people with dementia? A realist informed process evaluation. BMJ Open Qual 2021; 10: e001147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Zamboni K, Baker U, Tyagi M, et al. How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implement Sci 2020; 15: 27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Warring J, Crompton A. A ‘movement for improvement’? A qualitative study of the adoption of social movement strategies in the implementation of a quality improvement campaign. Sociol Health Illness 2017; 39: 1083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lowther HJ, Harrison J, Hill JE, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review. Implement Sci 2021; 16: 95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Williams SJ, Caley L, Davies M, et al. Evaluating a quality improvement collaborative: a hybrid approach. J Health Organisat Manag. 2022; 36: 987. [DOI] [PubMed] [Google Scholar]
- 10.Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8: 70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lalani M, Hall K, Skrypak M, et al. Building motivation to participate in a quality improvement collaborative in NHS hospital trusts in southeast England: a qualitative participatory evaluation. BMJ Open 2018; 8: e020930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Shaikh U, Lachman P, Padovani AJ, et al. The care and keeping of clinicians in quality improvement. Int J Qual Health Care 2020; 32: 480. [DOI] [PubMed] [Google Scholar]
- 13.Martin GP, Armstrong N, Aveling EL, et al. Professionalism redundant, reshaped, or reinvigorated? Realizing the “third logic” in contemporary health care. J Health Soc Behav 2015; 56: 378. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Fournier PL, Jobin MH, Lapointe L, et al. Lean implementation in healthcare: offsetting physicians’ resistance to change. Prod Plann Control 2021; 34: 493. [Google Scholar]
- 15.Dixon-Woods M, Campbell A, Aveling EL, et al. An ethnographic study of improving data collection and completeness in large-scale data exercises. Wellcome Open Res 2019; 4: 203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Suddaby R, Viale T. Professionals and field-level change: institutional work and the professional project. Curr Sociol 2011; 59: 423. [Google Scholar]
- 17.Muzio D, Brock D, Suddaby R. Professions and institutional change: towards an institutionalist sociology of professions. J Manag Stud 2013; 50: 699. [Google Scholar]
- 18.Carstensen K, Kjeldsen AM, Lou S, et al. The Danish health care quality programme: creating change through the use of quality improvement collaboratives. Health Pol 2022; 126: 749. [DOI] [PubMed] [Google Scholar]
- 19.Scott R. Lords of the dance. Organ Stud 2008; 29: 219. [Google Scholar]
- 20.Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York, NY: Dodd, Mead, 1970. [Google Scholar]
- 21.Bureau V, Kuhlmann E, Ledderer L. The contribution of professions to the governance of integrated care: towards a conceptual framework based on case studies from Denmark. J Health Serv Res Policy 2022; 27: 106. [DOI] [PubMed] [Google Scholar]
- 22.Institute for Health Care Improvement . The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement. In: Innovation series. Cambridge, MA: Institute for Healthcare Improvement, 2003. [Google Scholar]
- 23.Courtlandt CD, Noonan L, Feld LG. Model for improvement – part 1: a framewotk for health care quality. Pediatr Clin 2009; 56: 757. [DOI] [PubMed] [Google Scholar]
- 24.Dixon-Woods M. How to improve healthcare improvement—an essay by Mary Dixon-Woods. BMJ 2019; 366: l5514. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Brinkmann S, Kvale S. InterViews: learning the craft of qualitative research interviewing. 3rd ed. Los Angeles, CA: Sage Publications, 2015. [Google Scholar]
- 26.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77. [Google Scholar]
- 27.Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health 2019; 11: 589. [Google Scholar]
- 28.Aveling EL, Martin G, Armstrong N, Banerjee J, Dixon-Woods M. Quality improvement through clinical communities: eight lessons for practice. J Health Organ Manag 2012; 26: 158–174. [DOI] [PubMed] [Google Scholar]
- 29.Carstensen K, Kjeldsen AM, Lou S, Palmhøj Nielsen C. Implementation through translation: Implementation through translation: a qualitative case study of translation processes in the implementation of quality improvement collaboratives qualitative case study of translation processes in the implementation of quality improvement collaboratives. BMC Health Serv Res 2023; 23: 241. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Singh G, Cribb A. Aligning quality improvement with better child health for the 21st century. Arch Dis Child Educ Pract Ed 2021; 106: 370–377. [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Supplemental Material for Engaging health care professionals in quality improvement: A qualitative study exploring the synergies between projects of professionalisation and institutionalisation in quality improvement collaborative implementation in Denmark by Kathrine Carstensen, Joanne Goldman, Anne Mette Kjeldsen, Stina Lou, and Camilla Palmhøj Nielsen in Journal of Health Services Research & Policy.