Background

Sometimes learning is taken for granted in improvement practices, but what lies behind the taken for granted assumption? What is actually said when professionals discuss improvements and how does that impact on learning?

Healthcare, at least in Sweden, has been characterized by marketization the last 30 years which ultimately is about giving more power to patients. In practice, that means new payment systems, ever-changing care processes, increased transparency and comparisons to relate to. How does that affect the improvement talk? How do professionals handle the dilemma of giving the best individual care to each patient as they have the responsibility to create equal care for all?

Objective

The aim was to identify discursive patterns in an improvement practice and to discuss their conditions for learning.

Method

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic. Both the patient’s micro- and mesosystems were observed. The conversations were analyzed through critical discourse analysis (Fairclough 1992) with connection to a societal theory (Habermas 1987).

Findings

Four different discursive patterns were found that deal with (1) marketization, (2) equal care, (3) medical reasoning and (4) values from the patient’s perspective. The marketization pattern dominates the dialogue while money is linked to quality control. The findings show that professionals can handle the dilemma of improving the best individual care with equal care as long as quality measurements are not linked to payments. However, when measurements, as for example certain quality registers, are linked to monetary incentives the professionals turn to act for what is the most profitable thing to do.

Discussion

We discuss that market principles, as for example monetary quality control, impact on learning in terms of displacement effects. Professionals learn that each patient represents an economical value which shades deeper understanding of what actually creates value for patients.

References

Fairclough, N. (1992): Discourse and Social Change. Cambridge: Polity Press.

Habermas, J. (1987). The Theory of Communicative Action, Lifeworld and System: A Critique of Functionalist Reason. Vol 2. Boston: Beacon Press.