Confronting the Quality Paradox—Part 3
Biomed Central published a collection entitled The Many Meanings of “Quality” in Healthcare 19 June 2015. This collection was cross disciplinary and addressed three broad themes: the practices of quality assurance, giving space to “the story,” and addressing moral complexity in the clinic. This is the third of a series of articles dealing with individual papers that resonate with the practice of medicine today.
In contrast to the other two papers reviewed in this series, Farr and Cressey took a qualitative research approach to understanding staff perspective of quality in the practice of health care in a primary care service in Great Britain. Like other authors in this series, they emphasize the broad definition of quality in health care, both in Britain and the United States, includes two different attributes.
Within these definitions there are different aspects of quality where some facets rely on relationally based aspects of care (emerging from staff and patient interactions) whereas others are more functional and transactional and rationally calculable.
They go on to describe what they perceive as the assumptions underlying current efforts in both countries in rather vivid terms.
These [approaches] assume that public services can be disaggregated into specific, measurable units and that inputs and outputs (and their costs) can be accounted for and controlled…It is assumed that quality of services can be monitored and measured as part of wider performance management regimes that control explicit quantifiable units. This approach has its basis with a logic of formal rationality, based upon the reasonings of rational calculation, linear thinking, and formal measurement as a means of controlling the world. In health care this can lead to a focus on quality where that which can be measured is often focused upon rather than relational, interpersonal and affective dimensions of care.
In contrast to this rather mechanistic approach, they advocate for a system that takes advantage of insights of the services management literature.
Services have been defined as the use of knowledge and skills for another’s benefit. Services management literature highlights how service quality extends from a systemic and relational process that is co-created within the interactions between staff and service users…
Managing performance in knowledge work is often based on alignment with the motivation and values of workers, and can include professional networking, the sharing of knowledge, reflective spaces, team development and peer negotiated standards. The use of these approaches within health [care organizations] may begin to address the relational, knowledge in practice elements of interactive health services work, although they may be in contrast to more rational measurement systems that are currently in vogue.
Clearly, there are tensions here, and the tension between economic necessity and patient needs and preferences can create stress for front-line staff, particularly nurses. The authors posited that this tension was part of the problem of burnout and turnover. “The study examined what makes a difference to staff in being able to do a ‘good job,’ how they understood and accounted for this, and how they were enabled and motivated to improved the performance and quality of their work.” Their investigational approach does not translate into the “p<0.05” approach we are accustomed to reading. Their conclusions, though, resonate with my own experience, and perhaps they will with yours, too.
…This paper illuminates the importance of tacit, intangible and relational dimensions of quality in actual practice. Staff values and personal and professional standards are core to understanding how quality is co-produced in service interactions. Professional experience, tacit clinical knowledge, personal standards and values, and conversations with patients and families all contributed to how staff understood and assessed the quality of their work in everyday practice.
They found that conflict between the pressures of efficiency and patient-centeredness were real and omnipresent.
Clinicians spoke of the dilemmas they faced in working with large numbers of patients, whilst ensuring sufficient time was spent with each to provide the most effective service.
This is a pressure quite familiar to both physicians and nurses. Since the relational aspects of care are critically time dependent, an encounter that feels rushed and constrained will be less satisfactory to the patient than one that allows time for the issues to be addressed more fully even if the clinician feels the job has been done well.
Their bottom line conclusion and recommendation?
This study demonstrates how the management of quality in healthcare needs to extend beyond formalized policies and measures to acknowledge how care is a context-dependent and relational process. It argues against more measurement and suggests that where aspects of care are less easy to measure, management mechanisms based on trust and values may be appropriate.
The emphasis on tacit knowledge is one that I have made previously. I also have spoken to the importance of the tacit knowledge about “how we do things,” that is knowledge operating in a particular organizational context, is important for patient safety, and probably for quality. I have often talked about the disruptive effect of excessive staff turnover on attaining these goals. This series of articles emphasize that the current focus on “accountability” is likely leading to further dissatisfaction on the part of both providers and patients.
All of the articles in this series were written by British authors, and it is important to acknowledge that the organization and management of the National Health Service is substantially different from what passes for a system in the United States. But there is a similarity in that current “business” model here and the governmental and bureaucratic “new public management” there both devalue the personal and relational aspects of service care.
This is not malicious—it is simply a mistaken belief that one can/should be able to control something that is not fully controllable and not fully measurable. However, this is not to say that it cannot be measured (in some ways), predicted, or improved. I think we need to abandon the manufacturing analogies in medicine and we need to be wary of continuing to allow the “business” model to overshadow the fundamentally personal, and therefore moral, aspect of what health care organizations were established to do. We particularly need to be wary of the limits of the transactional approach that is the basis for good business thinking. As I have asked rhetorically in the past—when was the last time someone asked you how much of your medical advice they could have for $100?
Perhaps we would have more success if we thought of our clinical microsystems as the orbitals inhabited by electrons. The number and behavior of the orbitals can be predicted from the atomic chart, but the precise location of an electron at any moment in time is not knowable. Perhaps if we thought more about governance and leadership, as opposed to management, we could create cultures where the providers and their patients both thrived, and where stable teams could be established capable of learning together better ways to deliver care.
11 July 2015
 Swinglehurst D, Emmerich N, Maybin J, Park S, Quilligan S. Confronting the Quality Paradox: Towards New Characterizations of “Quality” in Contemporary Healthcare. BMC Health Services Research 2015;15:240. doi: 10.1186/s12913-015-0851y. Accessed at http://www.biomedcentral.com/1472-6963/15/240, 21 June 2015.
 Farr M, Cressey P. Understanding Staff Perspectives of Quality in Practice in Healthcare. BMC Health Svc Res 2015;15:123, doi. 10.1186/s12913-015-0788-1. Accessed 25 June 2015 at
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
Confronting The Quality Paradox - Part 5
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.