Abstract
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.
Highlights
Quality measurement that focuses on important processes and outcomes, including clinical care and patient experience, is often seen as an essential feature of well-functioning healthcare systems (Conway et al, 2013)
These differing goals of measurement embody a number of tensions, including those relating to the balance between stimulating improvement and provoking unintended consequences – such as gaming, effort substitution (Kelman and Friedman, 2009), shrinkage of professional responsibility and excessive bureaucratic burden associated with data collection and reporting (Chassin et al, 2010, Meyer et al, 2012)
As a more general principle, that quality improvement (QI) efforts founded in a particular logic may be overwhelmed by institutional logics operating at the field level
Summary
Quality measurement that focuses on important processes and outcomes, including clinical care and patient experience, is often seen as an essential feature of well-functioning healthcare systems (Conway et al, 2013). Measurement is deployed in the context of performance management regimes and as an element of pay-forperformance schemes to address the demand for accountability and transparency that has become one of the central tropes of current thinking on governance and regulation in modern healthcare (Mukamel et al, 2014, Brewster et al, 2016) These differing goals of measurement embody a number of tensions, including those relating to the balance between stimulating improvement and provoking unintended consequences – such as gaming (manipulation of data to look good), effort substitution (focus on the things being measured to the exclusion of other important activities) (Kelman and Friedman, 2009), shrinkage of professional responsibility (narrow focus on the things being measured) and excessive bureaucratic burden associated with data collection and reporting (Chassin et al, 2010, Meyer et al, 2012). The question of whether it is possible to capture the potential benefits of measurement while minimising the risks is a critical one
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