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Reliability Engineering and System Safety 125 (2014) 134–144
Contents lists available at ScienceDirect
Reliability Engineering and System Safety
journal homepage: www.elsevier.com/locate/ress
Applying different quality and safety models in healthcare
improvement work: Boundary objects and system thinking
Siri Wiig a,n, Glenn Robert b, Janet E. Anderson b, Elina Pietikainen c, Teemu Reiman d,
Luigi Macchi d, Karina Aase a
a
University of Stavanger, Department of Health Studies, N-4036 Stavanger, Norway
Florence Nightingale School of Nursing and Midwifery, King's College, London, United Kingdom
c
VTT, Tampere, Finland
d
VTT, Espoo, Finland
b
art ic l e i nf o
a b s t r a c t
Available online 28 January 2014
A number of theoretical models can be applied to help guide quality improvement and patient safety
interventions in hospitals. However there are often significant differences between such models and,
therefore, their potential contribution when applied in diverse contexts. The aim of this paper is to
explore how two such models have been applied by hospitals to improve quality and safety. We describe
and compare the models: (1) The Organizing for Quality (OQ) model, and (2) the Design for Integrated
Safety Culture (DISC) model. We analyze the theoretical foundations of the models, and show, by using a
retrospective comparative case study approach from two European hospitals, how these models have
been applied to improve quality and safety. The analysis shows that differences appear in the theoretical
foundations, practical approaches and applications of the models. Nevertheless, the case studies indicate
that the choice between the OQ and DISC models is of less importance for guiding the practice of quality
and safety improvement work, as they are both systemic and share some important characteristics. The
main contribution of the models lay in their role as boundary objects directing attention towards
organizational and systems thinking, culture, and collaboration.
& 2014 Elsevier Ltd. All rights reserved.
Keywords:
Patient safety
Quality improvement
Quality and safety models
Healthcare organizations
Hospitals
1. Introduction
1.1. Background
In healthcare there has for – at least the last decade – been an
ongoing debate about the human contribution to adverse events
with an increasing call for changing focus from individual models
to systems and organizational approaches to quality and safety
[1–5]. Drawing on experience from different industries healthcare
has moved in a direction characterized by a greater focus on
human factors, organizational learning, modification of staff attitudes, and culture [5]. However, unsafe medical care still causes
significant morbidity and mortality globally. Evidence from developed countries shows that between 3% and 16% of all hospitalized
patients are harmed by medical care [6].
Improving quality and safety in healthcare is predicated on
collaboration between healthcare professionals, managers, and
interaction across actors at different system levels [7–10]. There
are no easy solutions to the challenge of improving healthcare
n
Corresponding author. Tel.: þ 47 51834288.
E-mail address: siri.wiig@uis.no (S. Wiig).
0951-8320/$ - see front matter & 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ress.2014.01.008
quality and safety; much depends on the perspectives of users and
the attitudes and behaviors of professionals and managers, and the
contextual settings of organizations and healthcare teams [11,12].
Implementing evidence based practice or models of improvement
is challenging [13], and healthcare managers have generally been
slow to adopt and use research evidence [14,15].
The interest in safety theories and accident models (e.g Reason
and the Swiss cheese model; Rasmussen and the Socio-technical
risk management model), has emerged as a response to the
identified need for a system perspective in addressing adverse
events in healthcare [16,17]. Safety models have advanced from
being based on simple-linear causality to multiple-linearity to
non-linearity, and from being exclusively interested in accidents to
addressing the normal functioning of an organization. This development illustrates how the frame of reference for thinking about
patient safety and accidents has changed in the literature [18,19].
Quality improvement tools (e.g Total Quality Management,
Business Process Reengineering, the Institute for Healthcare
Improvements model for improvement, Lean thinking, Six Sigma)
have been widely used in hospitals to guide quality improvement
[10,20–22]. The quality improvement literature is large and
diverse, theories and models are not always well defined and
healthcare organizations often draw on a range of tools and
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S. Wiig et al. / Reliability Engineering and System Safety 125 (2014) 134–144
principles from different approaches [21]. Research has shown
evidence of improvement in quality, but there is no strong
evidence of the effectiveness of organization-wide or system
programs over a period of time [20]. There is growing awareness
that a solely technical approach to quality improvement will not
be sufficient to embed and sustain the organizational change
necessary to improve quality. Organizational and cultural factors,
such as leadership, values and goals, senior management commitment and communication and co-ordination are crucial to the
success of quality improvement initiatives [23].
There is an urgent need for targeted and well-designed
research to understand the causes of recurring deficiencies in
the quality and safety of health care [6], and to develop and test
practical solutions. Theoretical models have been applied to guide
health services research studies [22], to analyze medical errors,
and gain insight and new perspectives into key influences on
quality and safety [4,24–26]. There is less knowledge of how
healthcare organizations apply theoretical models in their own
efforts to improve quality and safety, and the implications of
applying different models that originate in different traditions of
safety science and quality improvement research.
1.2. Theoretical foundation of improvement models
Attempts to manage quality and safety, whether explicitly or
not are always based on underlying theories or models of
organizational and human behavior. Theories and models create
assumptions, expectations and suggest potential actions, thereby
directing attention to some issues more than others [18,27–31]. It
is unsurprising therefore that the different models and theories
used to guide quality improvement and patient safety work in
hospitals often have significant differences potentially leading to
diverse results [20,29,30,32,33]. Such theories and models can be
compared on a number of dimensions, such as their underlying
conceptualization of quality and safety. This can vary from assuming that quality and safety is a product or outcome of certain
formal processes or methods to viewing quality and safety as a
complex social process involving the human construction of
quality and safety [10,18,34,35]. Theories have been categorized
as either impact theories (describing hypothesis, assumptions,
cause, effect and factors determining success or failure) or process
theories (referring to the preferred implementation activities –
how they should be planned, organized, and scheduled to be
effective, and how the target group will utilize and be influenced
by the activities). The focus of a theory is important. Many theories
identify processes that should be undertaken in practice to
improve quality and safety, such as implementing interventions
or measuring outcomes. These are models of the process [30,31].
Other theories address specific components of the healthcare
system such as individuals [36,37], teams or technology (e.g.
Carayon, [38] the SEIPS model) which aim to shape how work is
conducted. Other models emphasize the organizational domains
that must be addressed to fully mobilize the resources required to
improve quality in its context [4,39].
1.3. Aim and research questions
The overall aim of this study was to address the current gap in
the literature on how healthcare organizations use theoretical
models in their own efforts to improve quality and safety. The
study describes and compares (1) the theoretical foundation of the
models: (a) the Organizing for Quality (OQ) model [10], and (b) the
Design for Integrated Safety Culture (DISC) model [40], and
(2) explores the practical application of the models and shows
how they have been applied to improve quality and safety in
practice in two European hospitals – one in England and one in
135
Finland. The choice of the two models to be compared, OQ and
DISC, was based on several criteria: our interest in a theoretical
comparison of improvement models with origins from different
traditions; curiosity in exploring the practical application of
dissimilar models in a hospital setting as examples of translating
knowledge into practice; and research experience with at least one
of the models in hospital settings amongst the authors (including
the originators of both the OQ and DISC models).
The following research questions have guided the study:
(1) What are the similarities and differences between the two
theoretical models?
(2) What are the similarities and differences between the applications of the models?
By analyzing the theoretical foundation of the OQ and DISC
models, and exploring how they have been applied, we illustrate
how they can contribute to improvement processes in practice. By
discussing the usefulness and role of theoretical models in hospital
settings and reflecting on how to select a model to underpin
improvement work, the study contributes to better understanding
of the translation of knowledge [41,42] and theoretical models
into practice.
2. Methodological approach
2.1. Research strategy
In this study we use a research strategy involving a theoretical
comparison of the OQ and DISC models, and a retrospective
comparative case study approach [43] of two hospitals, one in
England and one in Finland. The English case study explores how
the OQ model was applied in practical hospital improvement
work, while the Finnish case study covers the application of the
DISC model. There are diverse perspectives with regard to the
meaning of ‘case’ and ‘case study’ in the literature [44–46]. In this
study, cases are conceived as empirical units existing prior to the
study, not as theoretical constructs developed in the course of the
research process. The hospitals are the empirical units defined as
the cases which are scrutinized to explore how the two different
theoretical models contribute to the improvement of quality and
safety processes in the specific hospital contextual settings. The
case study research strategy is preferable when exploring a
complex phenomenon, and enables the researcher who deliberately wants to cover contextual conditions to incorporate them in
a holistic manner [43,47]. In this study, the latter is of particular
importance, as we cover quality and safety improvement processes that occurred in two different hospital contexts that are;
complex and interconnected involving multiple organizational
interfaces; and influenced by contextual conditions such as professional interests, previous competence, political and financial
pressure, technological development, and leadership [48,49].
Consequently, there is a need for a flexible research strategy in
order to understand how the two theoretical models were adopted
and used to improve quality and safety in practice [43].
2.2. Data collection
The data informing our study are based, firstly, on literature
relating to the OQ and DISC models [10,40], and secondly, on
retrospective analysis of the results of interviews, surveys and
document analyses undertaken in our two case study hospitals
[50]. Different approaches were used in the case study hospitals
and the methods used were informed by an action research
approach [51–53].
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2.2.1. English case
This case involves the application of the OQ model in an acute
hospital serving a patient population of approximately 180,000 with
approximately 2000 staff in England. The OQ model was used to guide
fieldwork conducted by a quality improvement facilitator over a three
month period in late 2008. Fieldwork comprised 42 face-to-face,
audio-recorded, semi-structured interviews, informal discussions,
and observations of day-to-day activities such as meetings and staff
interactions. The interviews were conducted with a selection of staff
from junior frontline staff to director level across different disciplines
and departments to provide a cross-organizational perspective of how
the organization currently manages change. Interviewees were asked
about a range of human and organizational factors based on their
experience of quality improvement initiatives in the hospital: what it
felt like to work for the organization, how change was viewed from
the position of leader, participant or observer, barriers to change and
potential areas for improvement. The interview data were analyzed
using a content analysis approach and the OQ framework. The results
are based on a case study report produced for the hospital senior
leadership team by the facilitator who was on secondment from a
national quality improvement agency. This report was subsequently
shared and discussed with one of the originators of the OQ model, the
second author of this paper (GR). The report is used as data material in
this study. Identifying details of the hospital have been anonymized for
the purposes of our brief case description.
2.2.2. Finnish case
The Finnish case hospital provides acute health care services
for 14 municipalities in Finland. The hospital employs approximately 1700 people and is organized into five distinct units. In
recent years the hospital has become known in Finland for its
visible patient safety improvement efforts. Between the years
2007–2011 several patient safety improvement efforts had been
carried out in the hospital (e.g. the implementation of a voluntary
incident reporting system as well as practices for supporting safe
work at the unit level such as a surgical checklist and a formal
process for identifying patients). However, there was a need to
understand whether the multiple distinct improvement efforts
had led the entire organization in the right direction and to decide
on the direction of future improvement work. In January 2011
researchers from VTT took part in evaluating and developing
safety culture in the hospital by applying the DISC model. The
purpose of the evaluation and development process, the basic
premises of the DISC model, and its application process (Fig. 3)
were discussed together with the top management of the hospital.
The aims of the evaluation and development process were to make
sense of where this specific hospital was in terms of safety and to
describe the effects of the efforts done in the case hospital so far.
In 2008 VTT had previously completed an evaluation of the patient
safety culture at the hospital. Methods used were TUKU safety
culture survey (n ¼454) [54] and 10 interviews. The interviews
covered the following topics: interviewee's own work, patient
safety as a concept, organizing of work at the hospital, and culture
of the hospital. This evaluation acted as a baseline measurement
for the 2011 evaluation and improvement process. In 2011 the
following data were collected: TUKU safety culture survey
(n ¼553), organizational documents (e.g. patient safety plan),
patient safety incident reports, and departmental qualitative
quality and patient safety reports. VTT researchers analyzed these
different types of data using both statistical analysis methods and
qualitative content analysis techniques.
2.3. Analysis
For the purpose of our comparative study we organized a
researcher workshop (2011) in which the initial theoretical
foundation analyses and comparison of the OQ and DISC models
was conducted. Based on literature underpinning the models and
direct researcher experience with each of the models our theoretical comparison emphasized the following key elements: theoretical foundation; origins; definition of core concepts; audience; single
level versus multi-level approach; outcome versus process focus;
normative versus descriptive orientation; purpose of model use; data
gathering tools requested; and the purposes of model applications.
The researcher workshop involved the Norwegian and Finnish coauthors and subsequently involved the English co-authors; hence
this analytical step was conducted by all researchers. The secondary analysis of the empirical data collection was conducted by the
authors involved; the English case study was described by GR
whilst the Finnish case study was described by EP, TR, and LM. All
researchers then performed the empirical cross case analysis using
findings from the single cases to analyze the practical application
and implications of the models in hospital improvement work. The
analysis of the practical implications focused on: how the models
were used; identified organizational improvement challenges (such as
structure, culture, leadership); and the implications relating to quality
and safety improvement processes.
2.4. Limitations
The single case studies were not initially designed with the
purpose of forming a comparative case study of the application of
the OQ and DISC models. It would have been preferable to have a
common protocol for the individual case studies with the comparison as part of the scope and purpose. However, our retrospective
approach means that we have conducted a theoretical comparison
of the models and then compared the use of these models in
practice settings and how they influenced improvement work.
The latter was initially part of the single case studies and therefore
enabled the retrospective comparison which is based on defined
criteria (see above) of how the models were useful or not for
practical improvement work. The use of an action research
approach implies that there was strong involvement from the
case study hospitals; this is evident in both single case studies but
in the English case study the adoption and use of the OQ model –
including data collection and analysis to support local implementation – was conducted by a local quality improvement facilitator.
3. Theoretical comparison
Below we describe the two theoretical models and present the
comparison of the models emphasizing similarities and differences between them.
3.1. The Organizing for Quality (OQ) model
The OQ model (Fig. 1) has its origin in the quality improvement
tradition, with a strong influence from organizational studies and
organization theory. It aims to understand the processes of
improving quality, both in the complex ways different organizational and human factors influence each other, and in how the
different levels of the organization and its outer context can make
these processes effective. The OQ model includes the inner and
outer context of organizations in its understanding of quality
processes. It focuses on organization size, structure and performance as influencing factors (inner context) in quality improvement. According to this model the political, social and regulatory
environments (outer context) also need to be addressed, to understand how quality improvement processes interact across system
levels (macro–meso–micro level) in the healthcare system. The
OQ's conceptualization of ‘Quality’ comprises three components:
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S. Wiig et al. / Reliability Engineering and System Safety 125 (2014) 134–144
137
Fig. 1. Six common challenges [10].
clinical effectiveness, patient safety and patient experience. The
model is based on research undertaken by the originators Paul
Bate, Peter Mendel, and Glenn Robert [10]. Based on in-depth,
multi-level case studies of seven leading hospitals (including from
the UK and the Netherlands), this research found that highperforming hospitals were able to achieve, and then sustain, high
levels of quality because they recognized and had been extremely
successful in addressing – on an ongoing basis – six common
challenges. The six common challenges that were identified from
the case studies were:
1. structural – organizing, planning and co-coordinating quality
efforts;
2. political – addressing and dealing with the politics of change
surrounding any quality improvement effort;
3. cultural – giving ‘quality’ a shared, collective meaning, value
and significance within the organization;
4. educational – creating a learning process that supports
improvement;
5. emotional – engaging and mobilizing people by linking quality
improvement efforts to inner sentiments and deeper commitments and beliefs; and
6. physical and technological – the designing of physical systems
and technological infrastructure that supports and sustains
quality efforts.
The researchers represented these common challenges by
means of a ‘codebook’ which took the form of a checklist that
practitioners can use to identify where the organizational gaps in
their local improvement efforts may lie and what they may need
to do to address them. Based on the systematic review and coding
of the organizational case studies, multiple illustrations of the
different types of challenges and solutions were extracted from
the individual case study narratives and assigned to the different
challenges. In total, the codebook includes 56 such solutions
spread across the six challenges, all derived ground-up from the
organizational cases themselves. The codebook defines each of
these solutions in turn, and illustrates how each may contribute to
sustained quality and service improvement in the health care
setting. In doing so, it seeks to help organizations to carry out a
search for a solution by: providing a checklist of the areas and
topics any quality improvement effort will need to cover, giving
improvement leaders a way of charting where they and their
organization are on their improvement journey, identifying any
‘gaps’ in their own quality improvement activities that will need to
be addressed (it can therefore be used as a self-administered
diagnostic tool), allowing implicit assumptions about the theory
and practice of quality improvement to surface and to be thought
about (a reflective model), and providing people with a model and
language for talking about the issues (a dialogical tool).
3.2. The Design for Integrated Safety Culture (DISC) model
The DISC model (Fig. 2) is a model for evaluating and developing organizations from a safety point of view. It is grounded in
safety science and especially safety culture and system safety
theories. The model has been developed based on theoretical
work and empirical case studies carried out in several safety
critical organizations in different domains, including nuclear
industry and healthcare. It is a normative model aimed at depicting the ideal characteristics (functions and safety objectives) of
safety critical organizations. The DISC model assumes that cultural
phenomena affect safety and they need to be taken into account.
The DISC model understands safety as an emergent property of the
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functioning of the entire socio-technical system. Safety culture
refers to the ability and willingness of the organization to take
care of the hazards and create safety. As safety is an emergent
non-reducible property of the system it needs to be studied and
developed through safety culture: safety culture can be seen as an
approximation of the potential the organization has for performing safely. The DISC model is also based on the premise that
cultural characteristics can be designed in the organizations.
Culture is something that is not easily managed or implemented
from top-down, however it is assumed that it can be systematically affected and steered by organizational structures, investments, technology and other organizational solutions as well as
everyday social interaction. The DISC model also emphasizes
integration. It assumes that safety should be integrated into normal
activities and that all the safety functions should be working
towards the same direction. Coherence should be strived for.
The DISC model describes six organizational-level criteria for
good safety culture (inner part of Fig. 2).
1. Safety is a genuine value in the organization and reflects to
decision making and daily activities.
2. Safety is understood as a complex and systemic phenomenon.
3. Hazards and core task requirements are understood
thoroughly.
4. Organization is mindful in its practices.
5. Responsibility for the safe functioning of the entire system is
taken.
6. Activities are organized in a manageable way.
These criteria can also be understood as the goals of safety
management. It is assumed that if an organization meets these six
organizational criteria in its structures and practices it can be said to
have good potential for safety or good safety culture. It is not
sufficient that the organization fulfills one or two of the criteria;
they are all needed in creating safety in everyday activities. In order
to be called organizational-level criteria, each criterion should
manifest itself in several elements of the organization. The criteria
should manifest in practices, structures and mindset of the personnel
as well as in their understanding. Besides the criteria, the DISC model
also depicts the functions: leadership, hazard management, strategy,
pro-activity, work processes, working conditions, competence, supervision, contractor relations, and change management (outer part of
the disc in Fig. 2) that need to be performed appropriately in an
organization in order for it to approach the six objectives [40].
3.3. Similarities and differences between the models
Table 1 summarizes the theoretical foundations for OQ and
DISC, their origins and purposes, conceptualization of core concepts, and how the models are intended to guide researchers and
practitioners in quality improvement and patient safety improvement. The models have their origins in diverse scientific traditions.
The OQ has its origin in quality improvement research using
organizational studies and organizational theory, while DISC has
its origin in safety science, safety culture, and system safety
theories. The core concept of the models differ. Whereas OQ
focuses on quality – in which safety is considered a subset – the
DISC model has a much more specific target and the center of
attention is safety and safety culture. Even though focusing
respectively on quality (OQ) and safety culture (DISC) both models
enact a process view and emphasize a systemic perspective
focusing on quality and safety as emerging from non-linear
interactions within the organization and with the environment.
Both models focus on quality improvement and safety processes in
their conceptualization of how quality and safety is achieved in
practice, even though DISC pays more attention to single variables
Safety
leadership
Change
management
Management of
contractors
Supervisory
activity
Hazard
management
Safety is a genuine value in the
organisation which reflects to
decision making and daily
activities
Responsibility
Hazards and core
for the safe
task requirements
functioning of
are understood
the entire
thoroughly
system is
taken
Safety is
understood as
Organization is
a complex and
mindful in its
systemic
practices
phenomenon
Activities are organised
in a manageable way
Safety
culture
Competence
management
Strategic
management
Pro-active safety
development
Work process
management
Work
conditions
management
Fig. 2. The DISC model (adapted from [40,55]).
than OQ. The OQ model is empirically driven and developed based
on longitudinal studies of high performing hospitals, while the
DISC is more theoretically based. This may be the reason for a
difference in the models' normative versus descriptive orientation.
They both attempt to guide improvement work by conceptually
distinguishing various domains of activity that are required to
improve quality. The DISC model is normative in the sense that it
describes the goal of improvement, the cultural characteristics that
should be present in a safety critical organization and towards
which the organization should be steered. OQ is also normative in
its emphasizing of the six common challenges that should be
addressed, but in addition OQ pays attention to the descriptive
aspect of how quality improvement processes occur in practice
and thus additional aspects and challenges emerge as themes.
In sum, both models aim to understand the processes, functions and characteristics necessary for organizations to improve
quality (OQ) and safety (DISC). The main differences relate to the
DISC model being more theoretically driven with a stronger link to
variables and quantitative measures compared to the OQ model.
The OQ model pays more attention to process explanations,
divides context into outer and inner context, and focuses more
on the interaction between macro, meso and micro levels in the
socio technical system.
4. Practical application
We now present descriptions of how the theoretical models
were applied in the case hospitals as part of practical efforts to
improve quality and safety, and compare similarities and differences between the applications of these two particular models.
4.1. Applying the OQ model in an English hospital
The context of the English hospital reveals a relatively small
organization in acute health care terms ‘with limited resources’
where it was ‘important that the hospital ran efficiently and that
staff felt supported to implement, manage and sustain improvement.’ The hospital management wanted to understand why
improvement was difficult to achieve and sustain. The aim was
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139
Table 1
Similarities and differences between the OQ model and the DISC model.
Aspects of the models
Organizing for quality (OQ)
Design for Integrated Safety Culture (DISC)
Origin and theoretical perspective
Quality improvement, organizational studies,
organizational theory.
To understand the process of improving quality,
both in the complex ways that different
organizational and human factors influence each
other, and in how the different levels of the
organization can make this process effective.
High-performing hospitals in the US and Europe.
Safety science, safety culture, system safety
theories.
To depict characteristics of organizations with
good safety culture and the functions needed for
developing those characteristics in the
organizations.
Purpose of model design
Design settings and context in which the model
was developed
Definition of core concept
Audience
Single level or multi-level perspective
Search for variables or processes
Outcome or process focus
Empirically or theoretically driven
Normative or descriptive model
For what purpose has the model been applied
Data gathering tools for applying the model
‘Quality’ comprises three components: clinical
effectiveness, patient safety and patient experience.
Quality is conceptualized in a social process
perspective.
Researchers, hospital leaders, quality improvement
specialists.
Multi-level perspective in the model including
macro, meso and micro level of the healthcare
system. Specify inner and outer context.
Process explanations
Mainly process.
Mainly empirical.
Mainly descriptive as the model does not describe
the functions that should be carried out in order to
improve quality or the criteria/characteristics of
good quality. Normative in the sense that is
emphasizes the general challenges every
organization faces and thus should manage.
Research and practical purposes.
Code book is developed for practitioners.
OQ can be used as a self-administered diagnostic
tool, reflective tool, dialogic tool.
Different types of data collection tools are needed. It
promotes a multilevel approach including macro,
meso, micro level in data collection.
Safety critical industries (e.g. health care, nuclear
industry, railways).
‘Safety’ is understood as an emergent property of
the functioning of the entire socio-technical
system.
Researchers, regulators, safety experts, managers,
personnel in safety critical organizations.
Single perspective in the sense that it focuses on
the organizational level (e.g. hospital). Multilevel
in the sense that safety culture is viewed as a
multilayered phenomenon.
Mainly variables.
Mainly outcome.
Mainly theoretical.
Descriptive in the sense that it seeks to
understand the culture in question and how the
control functions manifest in it. Normative as it
describes the six criteria of good safety culture and
the ten control functions necessary for achieving
it.
Research and practical purposes.
Evaluation and organizational development from
safety point of view.
DISC can act as a “boundary objecta”.
Different types of data collection tools are needed.
TUKU safety culture survey is developed based on
the DISC model.
a
A boundary object is something that is shared and sharable across different problem solving contexts. They can be processes, artefacts, documents, or technical
language or vocabulary in common use among practitioners [56].
not to ‘be prescriptive but aim to stimulate thought, discussion
and debate’ to inform the development of a quality improvement
agenda at the hospital (Quotes from the case report).
Preliminary results from the interviews were presented to key
individuals in the organization and a wider audience for additional
feedback, discussion and comment. The findings were presented in
the form of a written report that considered each of the six OQ
challenges (structural, political, cultural, educational, emotional,
and physical & technological) separately (although noting that
‘there are connections and overlap between them’). A selection of
quotations from interviews was provided to illustrate – in the
interviewees’ own words – the nature of the improvement challenges faced; these were grouped into twenty themes and organized under the six OQ challenges. The quotations were
highlighted to indicate whether each was from ‘directors & senior
management’, ‘middle management’ or ‘other staff’. A summary of
the facilitator's interpretation of the staff interviews was included
against each challenge in the report. Specific issues identified by
staff were also noted. Table 2 includes brief extracts from the report
illustrating how the material was organized and the format in
which it was fed back to senior management of the case hospital.
The analysis of the staff interviews identified a number of
issues for the hospital to consider as it developed a strategy to
build quality improvement capability. These were presented in the
report alongside examples from the Bate et al. [10] case studies of
examples of solutions used by the leading healthcare organizations that had been originally studied. These solutions were
‘presented to illustrate a range of responses made by high
performing organizations to the identified challenges in order to
assist discussion and consideration of the key issues facing the
organization in developing and implementing a quality improvement strategy and implementation plan’.
By applying the OQ model in practical improvement work the
overall results showed that (a) structural processes to support
quality improvement activity were lacking and it was recommended that a quality improvement effort should initially focus on
getting basic structures in place; and (b) the culture at the hospital
was a real strength; there was a strong, shared sense of organizational identity and a pride in the organizations many achievements which provided an emotional tie between staff and the
organizations and motivated staff to go the extra mile for patients,
colleagues and the hospital.
The practical use of the OQ model resulted in suggestions for
establishing a programme to build quality improvement throughout the hospital. The results showed that the following topics
should be addressed in that programme:
the lack of a link between various quality improvement
activities and the hospital's goals;
the lack of an infrastructure to support quality improvement
and the need for a process of planning, co-ordinating, measuring and monitoring improvement projects (whilst recognizing
that ‘any introduction of a more formal culture’ will need to be
carefully managed’);
initiatives to encourage teamwork, such as the formation of
multi-disciplinary, cross-functional teams;
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Table 2
Brief extract of findings from using the OQ model.
Quotations
Organizational structure and roles:
Current approach to quality improvement – scattergun,
not planned enough. Not enough account of other
workloads. Need someone to oversee and decide when
appropriate to implement with timescale [middle
management]
Findings
Issues
In terms of quality improvement the organizational structure
does not include formal quality improvement roles and
during interviews staff either did not know if anyone was
responsible for quality improvement, or they thought it was
the responsibility of the General Managers … a number of
staff felt that the organization should consider creating
formal roles and responsibilities for quality improvement to
provide leadership, focus and support.
Organizational silos
Approach to quality improvement – nothing structured
across the organization [other staff]
Group collaborative culture:
Can do. I love working here. Staff are amazing. There is a
[hospital] way. It feels great to work here. Everyone has a
part to play [other staff]
Forward thinking, passionate people. Ad hoc, reliant on
specific people and fall apart without them. No
processes. Change depends on who is involved and do
they have the right ear [directors & senior management]
No formal quality improvement
roles.
Responsibility for quality
improvement is unclear
executive sponsorship of quality improvement projects to
Collective shared culture and
organizational identity
The hospital has a very strong, positive and shared culture
and descriptions commonly used to describe this included
‘can do’, ‘family’, ‘forward thinking’, ‘patient-centred’ and
‘caring’.
There is a strong sense of organizational identity and a
strong ethos … the hospital is seen to value patients, patient
care and patient safety as well as achieving targets,
enhancing its reputation and saving money.
manage the ‘politics’ of staff engagement;
the hospital's strong organizational culture could be used to
leverage and embed a future quality improvement agenda;
provision of quality improvement training combined with a
process to share knowledge across the organization in order to
raise awareness of the quality agenda, provide ‘know how’ and
start to develop a critical mass of trained staff to spread and
sustain good practice;
implement a skills audit and talent management process to
overcome the problem of the same individuals being asked to
deliver change; and
provision of protected time, tools and resources to support
quality improvement to encourage staff to take ownership of
and effect change in their areas of control.
As a result of this diagnostic work informed by the OQ model, the
hospital developed a new quality improvement strategy ‘with the aim
of maintaining or improving the quality of care and patient safety in
the presence of severe financial constraints.’ Hospital Board papers in
April 2009 noted that, ‘It is recommended that an approach based on
improving services and quality is likely to gain greater organizational
support than a conventional cost reduction programme and be the
most effective way of delivering required efficiency gains. This
approach is based on the diagnostic work … over the past six
months’. The action plan for creating ‘a service improvement climate
within [hospital]’ was explicitly based on the six OQ challenges and
included 19 specific actions. The action plan including the creation of
a quality improvement guide and toolkit for all staff, and develop an
in-house quality improvement training capability. Moreover it
included the establishment of a variety of mechanisms to involve
staff in quality improvement work, for example, action learning sets,
rapid improvement events. It also emphasized that the Board of
Directors and Risk & Delivery Committee members needed to provide
leadership and visible support to quality improvement.
4.2. Applying the DISC model in a Finnish hospital
The typical process of applying the DISC model for evaluating
and supporting the development of an organization is described in
Fig. 3 (process direction is described by a bottom-up arrow from
the initial starting point 1 in the figure). After clarifying the
9.Taking the results into
account in everyday work and
improvement efforts
8.Communicating the
results
7.Summing up the results and
improvement suggestions
6.Reflecting on the results and
identifying development needs
(PERSONNEL SEMINAR)
5.Further data analysis
4.Reflecting on the results
(MANAGEMENT SEMINAR)
3.Analysing data
2.Gathering data
1.Clarifying the starting point for evaluation
Fig. 3. The process and responsibilities of the DISC model based evaluation and
development process.
purpose and guiding principles of the evaluation and development
process, data is systematically gathered and analyzed in order to
get an understanding of the safety culture in the hospital. Different
types of data gathering tools can be used. The TUKU safety culture
survey [54] has been developed to specifically address the functions depicted in the DISC model and to shed light on the six
criteria of good safety culture. In addition to the TUKU questionnaire, other means of data gathering are also needed in order to
form a complete picture of an organization's safety culture. For
instance interviews, workshops, incident reports, and document
analysis can be used in data gathering. Results of the process are
reflected upon in interaction with the hospital personnel and
development needs are identified. Results are then summarized
and communicated to the organization in order to facilitate the
implementation of the improvement efforts in the everyday work.
The application of the DISC model for evaluating and developing an organization relies on the following general assumptions:
the personnel must be involved in the evaluation and development process;
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S. Wiig et al. / Reliability Engineering and System Safety 125 (2014) 134–144
the process aims at helping the organization in getting an
overall picture of its culture and an estimation of the direction
the organization is heading in terms of the six criteria of good
safety culture;
the improvement efforts planned and carried out should be in
line with each other and they should be linked to other
improvement efforts going on in the organization;
an outsider can help to raise discussion on issues that the
organization does not consider or appear as too delicate to
bring up;
it is important for the outside expert to bring out his/her
assumptions as explicitly as possible
the DISC model can act as a “boundary object” between the
experts and the personnel, it can support the objectivity of the
evaluation and development, help in integrating different types
of data and support the communication between the experts
and the organization; and
safety culture improvement is a long span process that needs
constant attention.
The results from the Finnish case study showed continuous
informal interaction between researchers and the quality manager
of the hospital during the process of using DISC in practical safety
improvement work. In addition two formal interaction sessions
were organized as part of the process: a hospital management
group meeting and a feedback seminar day with the hospital
personnel (90 people attended). In these seminars researchers and
personnel at the hospital discussed and interpreted together the
findings from the different types of data. The seminars also offered
an opportunity to discuss and diagnose what kind of development
activities were already carried out in the hospital and how these
corresponded to the development needs that were identified
during the evaluation. In the personnel seminar the representatives from each of the organizational units planned what should
be done with the identified issues in the evaluation. Later the
results were also discussed in the management groups of each
organizational unit without the researchers being present.
The apparent strengths and challenges facing the hospital were
summarized by the Finnish researchers on the basis of the DISC
model. It was concluded that many aspects of safety culture had
improved in the hospital since 2008. More specifically, the results
showed that the safety investments made during the intervening
years had helped develop increased mindfulness in the organization and highlighted the importance of safety in the organization.
Safety thinking in the organization had also become more systematic and systemic in terms of – for example – implementation
of biannual quality and patient safety reports for establishing a
better overall picture of the status of the hospital in safety terms.
However, there was still a need to strengthen responsibility for the
safe functioning of the entire system instead of unit-specific safety
thinking. For example, in some cases well-intentioned safety
improvement efforts in one unit (such as refusing to take in extra
patients) caused safety problems in other units (overload because
patients could not be transferred). It revealed the need to consider
safety improvement in a more comprehensive manner and to
agree on the distribution of work between units. Understanding of
the hazards and core task requirements also needed more attention. The hospital had invested significant effort into pro-active
safety development, for example incident reporting and appointing experts responsible for patient safety issues and gathering
development groups, including patient representatives. However,
the results showed that safety thinking was still strongly connected to specific safety practices and persons and was not fully
integrated into everyday work. Moreover, the safety effects of
everyday decisions (e.g. concerning financial issues) were not
always systematically evaluated. Based on the findings, it was
141
further suggested that the hospital should develop its systematic
competence management towards the safety perspective. This
involved taking patient safety needs into consideration more
systematically and proactively in planning processes and changes
(e.g. new building construction projects, implementation of new
technology). In addition to the personnel meeting, results were
communicated to staff by means of a written summary which also
contained improvement suggestions. In the regional patient safety
bulletin a brief summary of what the results meant on an
individual level was also provided.
The improvement process based on the DISC model resulted in
specific outcomes related to strategies and practice. In April 2011
the Human Resource department of the hospital launched a new
personnel strategy for ensuring the adequacy of skillful personnel.
Even though patient safety was not the original reason for
launching it, the suggestions of the evaluation gave new meaning
and energy to the strategy. Later the organization also introduced
a new operations model for induction training; this organization
level induction training was formalised and reconsidered from a
patient safety point of view. More than a year after the start of the
evaluation and development process, the hospital was still working to take the suggestions of the evaluation into account in its
everyday practices. More recent efforts include the revision of the
plan for quality and patient safety. Relating to the suggestions
made in the evaluation, the new version of the plan aimed to
integrate safety efforts more clearly with the overall quality
improvement – and other core – functions of the organization.
In 2012, the quality manager started reviewing each of the
organization's operational functions (starting from technical services) in collaboration with the representatives of each function in
order to identify what ensuring patient safety meant in practice
for them.
4.3. Similarities and differences in applications of the models in
hospital improvement work
Our retrospective case studies of how different models were
applied in two hospitals demonstrate significant differences in the
use of methods, level of researcher involvement, data collection
tools, and type of data. In both case studies there was close
collaboration between researchers/facilitators and the hospital
management using an action research approach. One could expect
to find several differences in the practical application, results, and
the kind of improvement aspects addressed in both hospitals, as
the models differ significantly. However, what we found was that
the models focused attention and awareness on quite similar
dimensions in the case hospitals (for example, relating to issues
of structure, clarification of roles, responsibility, competence,
education, training, and culture). The application of both models
contributed to the establishment of new (or revision of existing)
structural elements in terms of strategies and plans in both case
hospitals. In the Finnish case hospital emphasis was placed on the
systematic improvement of personnel competence in terms of
patient safety in the new personnel strategy, and patient safety
was given more emphasis and became better integrated in the
overall quality effort at the hospital. Similarly we found that the
English case hospital developed a new quality improvement
strategy focusing on establishing formal structures for improving
service quality, and this strategy also emphasized a strong focus on
maintaining and taking advantage of the positive organizational
culture in ongoing improvement work. In both cases we found
staff involvement important albeit in slightly different ways. In the
Finnish case staff were involved in the entire evaluation process;
although this was also the case in the English case, the importance
of staff participation was emphasized additionally as a key element
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in the action plan that resulted from the diagnosis based on the
application of the OQ model.
In both case hospitals the application of the respective models
contributed to a systematic and systemic conceptualization or
operationalization of the quality and safety concepts. In the
English case this is evident in terms of elements in the programme
to build quality improvement throughout the hospital (e.g. understanding quality processes dependent on links between quality
improvement activities and hospital goals, and the role of team
work, the role of infrastructure, leadership and organizational
culture as important factors that shape quality processes). In the
Finnish case the model application contributed to a stronger
awareness of patient safety as a core concept of running a hospital
and a process dependent upon interactions across hospital units.
The results from both case studies also showed that the outer
context dimensions were not particularly prominent in the internal improvement processes in the hospitals. The internal processes
were directed towards improvement aspects that were possible to
manage internally, even though these aspects potentially could be
affected by external contextual dimensions such as regulation and
funding.
5. Discussion
Taking the theoretical comparison of the OQ and DISC models
into account together with the results from how the models have
been used in practical improvement efforts we argue that both
models are diagnostic in nature – they are designed to allow for
identification of organizational gaps that need to be addressed in
order to improve quality and safety. Since both of the models are
quite general they can be applied in a variety of ways and for
several purposes, for example, according to the audience and
whether or not the models are applied by researchers or
practitioners.
Our comparison showed that irrespective of the model used,
attention and awareness were directed along quite similar dimensions (structure, clarification of roles, responsibility, competence,
education, training, and culture) in the case hospitals. The importance of these dimensions is also highlighted in a recent largescale research programme in England where Dixon-Woods et al.
[57] concluded that improvement attention must be paid to
systems, culture, and behaviors. This implies: setting coherent
and challenging goals and monitoring progress towards them;
empowering staff; and encouraging and exemplifying sound
professional practice [57]. The reason for attention being paid to
similar dimensions in both our Finnish and English case hospitals
might be found in the theoretical comparison of the different
dimensions in the two models. The six challenges of OQ (structural, political, cultural, educational, emotional, and physical/
technological) correspond to several of the inner circle criteria
(values, complexity, core tasks, mindfulness, responsibility, and
organizing) and the outer circle functions (leadership, hazard
management, strategy, pro-activity, work processes, working conditions, competence, supervision, contractor relations, and change
management) of the DISC model.
The theoretical models differ with regards to how they incorporate and analyze the organizational context, and different
results could have been expected with regards to attention to
contextual aspects. The OQ model attends to both outer and inner
contextual factors in analyzing quality improvement processes
within the hospitals and how these processes are influenced by
the context relations (e.g why are patient experiences emphasized
by macro level organizations but not within the hospital meso and
micro level?). The DISC model also includes outer context interaction (e.g. managing contractor relations and supervisory
activity) but to a less specific level compared to the OQ. Interestingly, results from both case studies showed that the outer context
dimensions were not particularly prominent in the internal
improvement processes in the hospitals, even though the wider
literature often highlights the environmental conditions and outer
context as vital to inner context improvement work [7,58–60].
The interpretation of the implications of the models for
practice might be explained by other factors than the model
content and their theoretical foundation. It could be related to
the organizational context, organizational readiness for change
[61], leadership priority in quality and safety [62], researcher
involvement [52], and the role of the models as boundary objects
(see below) [56,63–66]. Such suggestions call for further research
to improve our understanding of how quality and safety theoretical models are translated and contribute to practical improvement processes.
Different theories and models have their strengths and weaknesses [67], and the choice of model in guiding improvement work
in hospitals, can vary from being more or less unsystematic to a
more rational choice. Based on our analysis of how the two
hospitals in our retrospective study used the two quality and
safety theoretical models in their practical improvement work, we
argue that an important aspect is how the different models both
operated as boundary objects directing attention towards organizational and system thinking, culture, and collaboration in
improvement processes. Both models acted as diagnostic, reflexive, and dialogic mechanisms linking key people within the
organizations, directing attention to certain aspects of the
improvement processes, and generating commitment in general
and especially among leaders enacting quality or safety. Our
findings are in accordance with the wider literature on boundary
objects as keys in knowledge interaction and sharing of meaning
[56,64,66]. A boundary object is something that is shared and
sharable across different problem solving contexts. They can be
processes, artefacts, documents, or technical language or vocabulary in common use among practitioners and are able to link
different social communities so that they can collaborate on
shared tasks. They are usually flexible enough in structure to
enable different interpretations in their meaning in different social
worlds, but robust enough to enable shared meaning and communication [56]. Studies of boundary objects in healthcare
demonstrate how they have been applied to enhance interprofessional collaboration [68,69] by using for example a specific
standardized communication tool [70]. In our cases the models
represented boundary objects. They were explicit in nature (something visible) [66] and provided a means for: discussion and
identification of quality and safety problems, bridging professional
hierarchies, collective learning, transforming knowledge into
goals, clarifying roles, and promoting a common culture between
professionals and leaders.
Our findings imply that awareness should be given to the
underlying assumptions of any model [30] to the extent that these
are relevant for considering what aspects will be discussed and
shared when using the model as boundary object [56,64,65]. In
our study, the underlying assumption in the OQ and DISC models –
that quality and safety needs to be at the core of organizational
performance – also emerged as a key theme during the diagnosis
and evaluation process in the case study sites. In both hospitals
attention was directed towards integration of quality and safety
into the ordinary tasks of running hospitals. Both hospitals
acknowledged the need for stronger integration (England) and
proactivity (Finland), along with specific tasks related to education
and training in order to increase attention to and socialize quality
and safety into the organizations. These are all in line with the
model assumptions and, as suggested by Allen [68], “quality” and
“safety” themselves are boundary concepts with strong cohesive
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power that facilitates communication and cooperation between
members of distinct groups without obliging members (such as
doctors, nurses and managers) to give up the advantages of their
respective social identity [68].
This study has contributed to a better understanding of the role
of theoretical models for practical improvement purposes. However, we acknowledge that questions remain about whether the
choice of model is important in determining success, and how
contextual factors influence the outcome of improvement work
should be explored in further work. There is also a need for further
research to understand the role of knowledge brokers [71] in
translating theoretical models into such practical improvement
work.
6. Conclusion
Our analysis of the OQ and the DISC model, and our case study
examples have shown that differences appear in both the theoretical foundations, and practical approaches and applications of the
two models. Nevertheless, the study has indicated that the choice
between the OQ and DISC models was of less importance for
practical improvement work than the role of the model as a
boundary object. Quality improvement requires collaboration
between professionals and managers from different disciplines.
This is challenging because they have different concerns and goals
and use different professional vocabularies. In the case study
hospitals, the models acted as boundary objects, assisting collaboration by presenting a coherent strategy for change, and directing attention towards organizational and system thinking, and
culture. This is in line with recent research that emphasizes the
importance of these factors in improving quality and safety in
healthcare [57].
Acknowledgments
The Patient safety as an asset in social and health care (SafetyAsset, Potilasturva in Finnish) has received funding from Tekes,
the Finnish Funding Agency for Technology and Innovation.
The authors would like to thank all informants for taking part
in the study and sharing their knowledge with us.
The authors also would like to thank the blind reviewers for
their valuable input in the revision process.
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