Department of Health Sciences, University of Leicester, Leicester, UK.
Lancaster Medical School, Lancaster University, Lancaster, UK.
Soc Sci Med. 2018 Feb;198:157-164. doi: 10.1016/j.socscimed.2017.12.033. Epub 2018 Jan 2.
Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST). Measuring four common patient harms in diverse care settings with the goal of supporting local improvement, the programme explicitly eschews a role for blame. The study design was ethnographic. We conducted 115 hours of observation across 19 care organisations and conducted 126 interviews with frontline staff, senior national leaders, experts in the four harms, and the NHS-ST programme leadership and development team. We also collected and analysed relevant documents. The programme theory of the NHS-ST was based in a logic of measurement for improvement: the designers of the programme sought to avoid the appropriation of the data for any purpose other than supporting improvement. However, organisational participants - both at frontline and senior levels - were concerned that the NHS-ST functioned latently as a blame allocation device. These perceptions were influenced, first, by field-level logics of accountability and managerialism and, second, by specific features of the programme, including public reporting, financial incentives, and ambiguities about definitions that amplified the concerns. In consequence, organisational participants, while they identified some merits of the programme, tended to identify and categorise it as another example of performance management, rich in potential for blame. These findings indicate that the search to optimise the benefits of measurement by controlling the risks of blame remains challenging. They further suggest that a well-intentioned programme theory, while necessary, may not be sufficient for achieving goals for improvement in healthcare systems dominated by institutional logics that run counter to the programme theory.
衡量质量和安全对于改善医疗保健具有重要作用，但容易产生意想不到的后果。一个经常提出的观点是，优化衡量标准的效益需要控制指责风险，但这是否可行仍不清楚。我们研究了一个名为 NHS 安全温度计（NHS-ST）的项目的回应。该项目在不同的护理环境中测量四种常见的患者伤害，旨在支持当地的改善，明确避免指责的作用。研究设计是民族志的。我们在 19 个护理组织中进行了 115 小时的观察，并对一线工作人员、国家高层领导、四项伤害的专家、NHS-ST 项目领导和开发团队进行了 126 次访谈。我们还收集和分析了相关文件。NHS-ST 的项目理论基于衡量改进的逻辑：该项目的设计者试图避免将数据用于任何除支持改进以外的目的。然而，组织参与者——无论是一线还是高层——都担心 NHS-ST 潜在地充当了指责分配装置。这些看法首先受到问责制和管理主义的场域逻辑的影响，其次受到该计划的具体特征的影响，包括公开报告、财务激励以及关于定义的模糊性，这些特征放大了人们的担忧。因此，尽管组织参与者认同该计划的一些优点，但他们倾向于将其视为绩效管理的另一个例子，具有潜在的指责风险。这些发现表明，通过控制指责风险来优化衡量标准效益的努力仍然具有挑战性。此外，它们还表明，尽管良好的项目理论是必要的，但在以与项目理论相悖的制度逻辑为主导的医疗保健系统中，实现改进目标可能还需要其他因素。
