Abstract
BackgroundNational standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day services (7DS), from an organisational behaviour perspective.MethodsWe conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response.ResultsSenior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations.ConclusionsNational standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by resources and tailored support for improvement, taking into account local context and organisational culture.
Highlights
National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands
In their study of organisational responses to external demands for finance and quality, Burnett et al [3] found that positive responses were fostered by perceived coherence of the external demands, managerial competence to align demands with an overall quality improvement strategy, and managerial stability
We investigated how organisations responded to national quality standards, and the factors that shaped organisational response, in a sample of National Health Service (NHS) hospital trusts in England during the introduction of the national policy of 7-day service standards (7DS)
Summary
National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. In their study of organisational responses to external demands for finance and quality, Burnett et al [3] found that positive responses were fostered by perceived coherence of the external demands, managerial competence to align demands with an overall quality improvement strategy, and managerial stability. When these factors were absent, organisations were more likely to respond with habitual or symbolic compliance decoupled from improvement efforts
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