The Cult Value of Quality Improvement in Healthcare: Complex Social Processes of Working With Targets

There has been an ongoing debate on quality and what constitutes quality improvement in healthcare for several decades. Several authors identify that defining quality is an important part of that debate, yet recognise that quality is defined differently by different interests (Caper, 1988; Harteloh, 2003). Harteloh's distinction between quality as a property (a descriptive approach) and quality as a category of judgment (a prescriptive approach) has influenced the conception of quality as a property of participation emerging in this research. This is in stark contrast to the wide spread prescriptive approach set out in published accounts of quality and quality improvement. In the mainstream management literature, conventionally organisations are understood as systems and this conceptualisation underpins many published considerations of quality. In this way of thinking, those involved in leading quality improvement are thought to operate as autonomous individuals who design improvement tools and control improvements according to plans. It is taken for granted that it is possible for a powerful individual to step out of the organisational system and treat it as an object for manipulation and change, following the diagnosis of problem areas and gaps. Yet at other times that autonomous individual becomes part of the system and is subject to manipulation and change by others. As with much of the literature of change management, this approach sets "thought" before "action". In other words, "thought" is understood as the formulation of a plan and "action" is the implementation of that plan. In this thesis, it is my contention that this way of thinking leads to a privileging of the more mechanical and cybernetic elements of quality improvement - such as tools and techniques of waste elimination and fault detection, and, of particular interest in this thesis, the use of national targets in the public sector. My research is underpinned by a complex responsive processes perspective (Stacey, Griffin and Shaw, 2000). Central to this theory of human interaction is the importance of understanding everyday experience from the perspective of inquiring into “…just what is it that we are doing in our groups or in our organisations that leads to emergent patterns that are our experience…” (Stacey, 2003c: 32). In this thesis, I take up a key question raised by Stacey (2006) concerning how those working in the public sector institutions are operationalising central government governance requirements. I explore my experience of working locally with nationally determined performance targets for access to emergency care. I argue for consideration of quality improvement as a cult value along the lines defined by Mead (1923). In conceptualising quality improvement in this way, my inquiry focuses on what happens as we try to make sense of the ways in which our daily activities are being influenced by competing ideologies, by power relations that are played out, and by the enabling and constraining aspects of going on together in patterns of conversation. These are the complex social processes of working with targets I refer to in the title of this thesis. It is my contention that this perspective draws attention to quality as a property of our own participation as managers, rather than the more usual exhortations to look for the next tool for instilling quality into the organisation. As such, I argue that this research makes an important contribution to the ongoing debate on quality, as well as managerial practice. I propose that the participative and socially reflexive nature of the qualitative methodology involved provides a practical example of Mode 2 research, addressing what MacLean, MacIntosh and Grant (2002) identify as a current gap in the literature. Finally, I posit a potential contribution to policy making seeking to address a growing recognition from some policy makers regarding what is now being seen as an increasing problematic reliance on traditional, modernist assumptions of programmatic change.