In the last decades many different policy changes have been initiated in the Dutch hospital sector to optimise health care delivery: national agenda-setting, increased competition and transparency, a new system of hospital reimbursement based on diagnosis-treatment-combinations, intensified monitoring of quality, and a multi-layered organisational development programme based on quality improvement collaboratives – the multi-level quality collaborative (MQC). The focus of this dissertation is on the implementation and effects of the MQC. Several studies are described that help to answer two main research questions: (1) Did the participation by hospitals in the MQC result in the development of an organisational infrastructure for improvement, stimulating the adoption and sustainable spread of innovations and, if so, by what mechanism? (2) Is there, judged from changes that took place at different levels within the hospitals, any evidence that the MQC contributed to aligning the behaviour of staff at unit level with norms at national level via the behaviour of the strategic management? With regard to the first question, it is probable that the programme has contributed to quality improvement. Hundreds of improvement projects have been implemented within the MQC hospitals. Individual projects have shown positive results, but the performance indicator outcomes or perceived effects of a substantial part of the teams are unknown. Furthermore, different studies point at an organisational development effect. The strategic and tactical hospital management followed a systematic strategy on behalf of sustainability and spread; a strategy based on clear norms at organisation level, performance agreements, provision of necessary facilities and resources, and recurring accountability moments. The organisational infrastructure is adjusted to facilitate the implementation of the strategy. A longitudinal analysis suggests that programme hospitals evolved faster than the other hospitals. Three assumptions were explored to answer the second question: (a) competition and public communication of feasible quality norms, trigger hospitals to maximise quality (sector level), (b) MQC participation leads to systematic quality control (hospital level), (3) medical staff implements changes to achieve quality norms defined at higher levels (unit level). This dissertation demonstrates that planned change processes at different levels took place and were interrelated. Professionals adopted quality norms, took measures to realise the goals and measured performance-indicators. Improvement rates were confirmed as predictors for the future dissemination of the projects. This is an example of the continuous quality improvement that is being embedded at institutional level throughout the sector, not only within MQC-hospitals. During the programme, moreover, the behaviour of hospital executives did influence the extent to which the behaviour of project teams and physicians at unit level was aimed at achieving the MQC norms formulated at sector level. The MQC encouraged executives to do this in two ways. In the first place by adopting the organisational strategy for sustainability and dissemination. Secondly, by stimulating physicians to join quality improvement initiatives. As such, the MQC has contributed to a mechanism, linking quality targets at sector level to processes and outcomes at unit level
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