The Logics of Healthcare – In Quality Improvement Work

Abstract: 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.