Caring Peripheries:How care practitioners respond to processes of peripheralization

The centralisation of acute health care is a key policy concern in many countries. Less attention has been given to the side effects of centralisation: peripheralisation, occurring mainly in rural areas and post-industrial towns. In this research, we start filling this gap by exploring how this trend of concentration of health care can contribute to a phenomenon referred to as ‘discursive peripheralisation’. This article contributes to the literature on discursive peripheralisation by focusing on how actors, in our case acute care practitioners, cope with or oppose such processes. We draw on empirical data from two healthcare regions in different geographical contexts in Norway and The Netherlands. In these regions, we zoom in on the work of care practitioners and how they, in relation to care organisations and local authorities, aim to organise care for patients in ‘the periphery’ and how this contributes to more diverse and alternative narratives and practices of health care in these areas. Our findings offer important insights for both rural and regional policy. We conclude that other narratives, for instance, about perceptions of quality of care should be considered to avoid too much emphasis on the disadvantages faced by peripheral areas, compared to their urban counterparts

Using institutional theory to analyse hospital responses to external demands for finance and quality in five european countries

OBJECTIVES: Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands. METHODS: An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals. RESULTS: How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures. CONCLUSIONS: The development of hospital leaders' skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required

Prospects for comparing European hospitals in terms of quality and safety

Purpose. Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients’ rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway). Main Challenges Identified. The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country. Conclusion. Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries

Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention)

Objective To describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme. Design Qualitative design, using the participation of stakeholders. Methods The leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis. Setting Norwegian nursing homes and home care services. Participants Managers at different levels in three nursing homes and two home care services, coresearch

Talking about quality: exploring how 'quality' is conceptualized in European hospitals and healthcare systems

Background: Conceptualization of quality of care – in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. Methods: This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). Results: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. ‘Quality’ in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. Conclusion: The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts

Enacting quality improvement in ten European hospitals

_Background:_ Hospitals undertake numerous initiatives searching to improve the quality of care they provide, but these efforts are often disappointing. Current models guiding improvement tend to undervalue the tensional nature of hospitals. Applying a dualities approach that is sensitive to tensions inherent to hospitals’ quest for improved quality, this article aims to identify which organizational dualities managers should particularly pay attention to. _Methods:_ A set of cross-national, multi-level case studies was conducted involving 383 semi-structured interviews and 803 h of non-participant observation of key meetings and shadowing of staff in ten purposively sampled hospitals in five European countries (England, the Netherlands, Portugal, Sweden, and Norway). _Results:_ Six dualities that describe the quest for improved quality, each embracing a seemingly contradictory feature were identified: plural consensus, distributed connectedness, orchestrated emergence, formalized fluidity, patient coreness, and cautious generativeness. _Conclusions:_ We advocate for a move from the usual sequential and project-based and systemic thinking about quality improvement to the development of meta-capabilities to balance the simultaneous operation of opposing ideas or concepts. Doing so will help hospital managers to deal with major challenges of change inherent to quality improvement initiatives

Talking about quality: How 'quality' is conceptualized in nursing homes and homecare

Background: The delivery of high-quality service in nursing homes and homecare requires collaboration and shared understanding among managers, employees, users and policy makers from across the healthcare system. However, conceptualizing healthcare professionals’ perception of quality beyond hospital settings (e.g., its perspectives, defining attributes, quality dimensions, contextual factors, dilemmas) has rarely been done. This study therefore explores the meaning of “quality” among healthcare managers and staff in nursing homes and homecare. Methods: The study applies a cross-sectional qualitative design with focus groups and individual interviews, to capture both depth and breadth of conceptualization of quality from healthcare professionals in nursing homes and homecare. We draw our data from 65 managers and staff in nursing homes and homecare services in Norway and the Netherlands. The participants worked as managers (n =40), registered nurses (RNs) or assistant nurses (n =25). Results: The analysis identified the two categories and four sub-categories: “Professional issues: more than firefighting” (subcategories “professional pride” and “competence”) and “patient-centered approach: more than covering basic needs” (subcategories “dignity” and “continuity”). Quality in nursing homes and homecare is conceptualized as an ongoing process based on having the “right competence,” good cooperation across professional groups, and patient-centered care, in line with professional pride and dignity for the patients. Conclusion: Based on the understanding of quality among the healthcare professionals in our study, quality should encompass the softer dimensions of professional pride and competence, as well as a patient-centered approach to care. These dimensions should be factors in improvement activities and in daily practice

Управление процессом привлечения клиентов (на примере деятельности «Афина фитнес»)

Российский рынок фитнес-услуг активно растет и развивается, поэтому проблема привлечения клиентов к занятиям спортом остается актуальной. В данной статье определены наиболее удачные способы и методы привлечения потенциальных клиентов на примере фитнес-клуба г. Екатеринбурга «Афина фитнес». Проведен анализ различных опросов и маркетинговых исследований, который позволил определить наиболее важные факторы, способствующие привлечению посетителей в фитнес-клуб