Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST). Measuring four common patient harms in diverse care settings with the goal of supporting local improvement, the programme explicitly eschews a role for blame. The study design was ethnographic. We conducted 115 hours of observation across 19 care organisations and conducted 126 interviews with frontline staff, senior national leaders, experts in the four harms, and the NHS-ST programme leadership and development team. We also collected and analysed relevant documents. The programme theory of the NHS-ST was based in a logic of measurement for improvement: the designers of the programme sought to avoid the appropriation of the data for any purpose other than supporting improvement. However, organisational participants - both at frontline and senior levels - were concerned that the NHS-ST functioned latently as a blame allocation device. These perceptions were influenced, first, by field-level logics of accountability and managerialism and, second, by specific features of the programme, including public reporting, financial incentives, and ambiguities about definitions that amplified the concerns. In consequence, organisational participants, while they identified some merits of the programme, tended to identify and categorise it as another example of performance management, rich in potential for blame. These findings indicate that the search to optimise the benefits of measurement by controlling the risks of blame remains challenging. They further suggest that a well-intentioned programme theory, while necessary, may not be sufficient for achieving goals for improvement in healthcare systems dominated by institutional logics that run counter to the programme theory

How collaborative are quality improvement collaboratives:A qualitative study in stroke care

BACKGROUND: Quality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing. METHODS: We interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories. RESULTS: Improvements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants’ experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants’ competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support. CONCLUSIONS: Collaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement

Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia

We investigated the effects of water swallowing, pharyngeal stimulation, and oropharyngeal anesthesia on corticobulbar and craniobulbar projections to human swallowing musculature. Changes in pathway excitability were measured via electromyography from swallowed intraluminal pharyngeal and esophageal electrodes to motor cerebral and trigeminal nerve magnetic stimulation. After both water swallowing and pharyngeal stimulation, pharyngoesophageal corticobulbar excitability increased (swallowing: pharynx = 59 ± 12%, P < 0.001; esophagus = 45 ± 20%, P < 0.05; pharyngeal stimulation: pharynx = 76 ± 19%, P < 0.001; esophagus = 45 ± 23%, P = 0.05), being early with swallowing but late with stimulation. By comparison, craniobulbar excitability increased early after swallowing but remained unaffected by pharyngeal stimulation. After anesthesia, both corticobulbar (pharynx = -24 ± 10%, P < 0.05; esophagus = -28 ± 7%, P < 0.01) and craniobulbar excitability showed a late decrease. Thus swallowing induces transient early facilitation of corticobulbar and craniobulbar projections, whereas electrical stimulation promotes delayed facilitation mainly in cortex. With removal of input, both corticobulbar and craniobulbar projections show delayed inhibition, implying a reduction in motoneuron and/or cortical activity