Background: The implicit assumption of quality improvement (QI) is that a good structured and organisation-wide approach leads to better work processes. Improving work processes will lead to improved outcomes. But is this assumption valid, particularly in the somatic long-term care to the elderly? The aim of the study is to explore how QI initiated by feedback on client-related outcomes works in daily practice and to look for the most successful structure, process, and outcome factors in realising QI.
Methods: This study used a mixed methods approach. It is based on 434 facilities of long-term care to the elderly of whom three outcomes were known in 2007, 2009, and 2011. We used quantitative methods to determine best and worst practices with regard to client-related outcomes and qualitative methods to identify crucial structure, process, and outcome factors in a selected sample of long-term care facilities that were reported by stakeholders to be of importance in realising QI.
Results: Culture and leadership were the most important factors that differed between best and worst practices. We learn from best practices that QI was organised close to the client and that professionals used outcome elements to improve, in the contact with the clients.
Conclusions: To improve the QI activities in somatic long-term care to the elderly, culture and leadership of facilities are essential factors. This study emphasised the importance of analysing clientrelated outcomes, to give insight into the mechanism of QI in the somatic long-term care to the elderly in order to be more successful in QI.

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Keywords Culture, Leadership, Long-term care, Management, Performance measures, Quality, Quality improvement
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Journal International Journal of Healthcare Management
Winters-van der Meer, A.C.M, Kool, R.B, Huijsman, R, & Klazinga, N.S. (2015). Exploring day-to-day improvement in somatic long-term care in the Netherlands; a mixed method multiple case study. International Journal of Healthcare Management, 8(3), 164–172. doi:10.1179/2047971914Y.0000000098