Riding The Waves Of Quality Improvement

Increasingly, sustainability and spread have become part and parcel of organizational strategy in health care. This applies in particular to organizations in the long-term care sector, which faces an increasing care demand, ageing population and labor shortage. Unfortunately, sustainability and spread of quality improvement have been understudied. Given the dominance of project-based evaluation research, deeper insight in the dynamics and interplay between care organizations, improvement projects and care practices is lacking. Such insight is desired because sustainability and spread of quality improvement represent a conditio sine qua non for sustainable change at the system level.

This dissertation offers a theoretical framework for sustainability and spread of changed care practices based on organization theory: routine theory and Scandinavian institutional theory. Based on this framework measurement instruments were developed and new research designs were experimented with, including, analysis of care indicatordata, a small n case study, Latent Class Analysis, and longitudinal designs. The setting of research concerns the Dutch ‘Care for Better’ quality improvement collaborative (QIC) program for long-term care (2005 - 2012). The program was based on Breakthrough Improvement Methodology. In the ‘Care for Better’ program, improvement teams worked on implementing best practices during one year.

This dissertation offers an in-depth, integrated evaluation of the ‘Care for Better’ program in view of the context of the developments in the long-term care sector. Regarding the effectiveness of the program, it is concluded that the program yielded only partially sustainable change, mainly because the internal spread within the care organizations lagged behind. Based on the findings, it is concluded that sustainability and spread of changed care practices are not guaranteed by mere project effectiveness. These two concepts should not be conflated, but require related yet specific processes in care organizations. Sustainability and spread should be part and parcel of the improvement process from the start, rather than configured as a final stage. What is more, quality improvement set demands on the organizational capacity for improvement, and thus requires substantial adaptation from an organization to yield sustainable change. Last, following routine theory, the role of materials in care practices as well as in improvement practices appears vital for sustainability and spread; and therefore deserves more consideration in health policy as well as in the evaluation of quality improvement.