Context

Observations were made at clinical ward meetings and process team meetings at an orthopedic- and rheumatology clinic in Sweden. Mostly nurses and assistant nurses participated along with their manager at the clinical ward meeting. The process team consists of staff from the patient’s process which in this case includes physicians, nurses, physiotherapists and occupational therapists from both primary and specialist care. The improvement work in both meetings is facilitated by a developmental leader.

Problem 

Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. Given that learning sometimes is taken for granted in quality improvement work, this study set out to address what actually is said when professionals discuss improvements and how discursive patterns influence learning.

 Assessment of problem and analysis of its causes

 The study has an explorative qualitative design to investigate how discursive patterns occur in quality improvement conversations which means that quantified measuring was not appropriate.

 The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings. Assessment of problem and analysis of causes was a mutual effort from both researchers and staff. Ideas for improvements came up during the learning seminars when the researchers highlighted findings.

 Intervention 

The study had not an interventional purpose.

Study design 

A starting point in the methodology is that language is tightly connected to social learning. Five observations of quality improvement conversations were made and transcribed to texts. The conversations were analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). A framework of specific questions was constructed to guide the analytical process in Faircloughs’ three steps of description, interpretation and explanation.

Strategy for change 

As the study used a participatory research design, implementation, in its right term, was not needed because the staff saw what they needed to improve along with feedback and analysis from the researchers.

Measurement of improvement 

Methods, see questions 3 and 5 above.

Results

Four discursive patterns were found in the talk of improvements. We have named them the marketization pattern, the care-for-all pattern, the medical pattern and the value pattern. The marketization pattern dominates the dialogue while money is linked to quality control. The results also showed a balance between discourse patterns when money incentives were absent. In other words, professionals tend to integrate complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when improvement goals are linked to monetary incentives the professionals talk about what is the most profitable thing to do.  

Effects of changes 

See questions 3 and 4 above.

Lessons learnt 

The discourse order indicates that market principles impact on learning in terms of displacement effects. In a short term perspective, professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients. Learning based on inter-professional shared understanding, in this case about how orthopedic care processes could improve, is set aside.

The study implicates the importance of a balancing perspective on quality management if no quality aspect is to be left behind. Replicating studies in other contexts would be interesting to perform.

Message for others: What is the main message based on the experience that you describe here that you would like to convey to others? Discuss what your findings mean for patients and/or systems of care.

Money incentives promote learning about economical values and not what creates value for patients.

Please declare any conflicts of interest below 

The study is part of the research project Bridging the Gaps which is financed by Vinnvård. Otherwise no other conflict of interest is to be declared.