Introduction

Various forms of money incentives, for example Pay for Performance programs, are used to increase the pace of improvements in contemporary health care systems. In practice, that means new payment systems, increased transparency and comparisons to relate to. Given that learning sometimes is taken for granted in implementation work, what is actually said when professionals discuss improvements? This study identifies discursive patterns when an orthopedic team discusses their improvement data and problemetizes how these patterns create conditions for learning.

Methods

Five observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. The conversations were transcribed and then analyzed through critical discourse analysis to identify discursive patterns and their interrelated discourse order (Fairclough). The study used a method of interpretation with Habermas’ societal theory of system and lifeworld as a point of departure.

Results

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 results also show a balance between discourse patterns when money incentives were absent. In other words, professionals can handle complex, and sometimes contradicting, quality aspects when they don’t compete about money. However, when implementation goals are linked to monetary incentives, the professionals turn to act for what is the most profitable thing to do.

Discussion

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.