Knowledge management infrastructure to support quality improvement: A qualitative study of maternity services in four European hospitals.

The influence of multilevel healthcare system interactions on clinical quality improvement (QI) is still largely unexplored. Through the lens of knowledge management (KM) theory, this study explores how hospital managers can enhance the conditions for clinical QI given the specific multilevel and professional interactions in various healthcare systems. The research used an in-depth multilevel analysis in maternity departments in four purposively sampled European hospitals (Portugal, England, Norway and Sweden). The study combines analysis of macro-level policy documents and regulations with semi-structured interviews (96) and non-participant observations (193 hours) of hospital and clinical managers and clinical staff in maternity departments. There are four main conclusions: First, the unique multilevel configuration of national healthcare policy, hospital management and clinical professionals influence the development of clinical QI efforts. Second, these different configurations provide various and often insufficient support and guidance which affect professionals' action strategies in QI efforts. Third, hospital managers' opportunities and capabilities for developing a consistent KM infrastructure with reinforcing enabling conditions which merge national policies and guidelines with clinical reality is crucial for clinical QI. Fourth, understanding these interrelationships provides an opportunity for improvement of the KM infrastructure for hospital managers through tailored interventions.

Hybrid practices as a means to implement quality improvement: A comparative qualitative study in a Dutch and Swedish hospital.

BACKGROUND: Managers and scholars commonly perceive resistance from professionals as hampering the implementation of quality improvement (QI) and refer to the incompatibility of clinical and managerial approaches to QI as a reason. Yet a growing body of research indicates that, in practice, these two approaches rather blend into hybrid practices that embody different types of QI-related knowledge and values. This opens up a new perspective on implementation challenges that moves attention away from resistance against managerial QI toward difficulties for clinicians to draw together different types of knowledge and values within their clinical work. So far, little is known about how managers can support clinicians to generate hybrid QI practices. PURPOSE: The aim of this study was to deepen our understanding of how managers can support the generation of hybrid practices that help clinicians to integrate QI into their everyday work. METHODOLOGY/APPROACH: We draw on comparative qualitative research including 21 semistructured interviews, documentary analysis, and participant observation that we conducted in one Dutch and one Swedish hospital over a period of 8 months in 2011/2012. RESULTS: Hospital managers designed hybrid forums, tools, and professional roles in order to facilitate the integration of different QI practices, knowledge, and values. This integration generated new hybrid practices and an infrastructure for QI that has potential to support clinicians in their efforts to align different demands. PRACTICE IMPLICATIONS: New opportunities to implement QI emerge when we change the implementation problem from clinical resistance to the need of support for clinicians to develop hybrid QI practices. Hospital managers then have to intentionally organize for the generation of hybrid practices by designing, for example, hybrid forums, tools, and professional roles that integrate different knowledge and values in a nonhierarchical way.