Measuring quality (MASQ): Exceeding the limitations of quality management in municipal health and care services

For decades, public governance has aimed for increased quality and efficiency of the Norwegian municipal health and care services. This goal has enjoyed widespread support; stakeholders generally desire high-quality service delivery. Yet, precise definitinos of quality, are hard to come by. And efforts to create quality - through reforms, increased health and care expertise demands, preparations for a demographic aging of society, and so on, has been faced with a paradox: As sectors grow more complex, the task of defining a shared concept of quality grows more complex as well. A preferred strategy for solving this conundrum in policy and practice has been to introduce performance and quality indicator systems for measurement and transparency purposes. The municipal health and care services are no exception. Yet, unintended effects of such systems have also been documented in previous organizational research. This research points to a tendency for service delivery to become increasingly standardized, and that changes may occur in the attitudes and behaviours of management and health and care personnel regarding which work tasks matter the most. As a well-known slogan says, what is measured is what counts. Through a qualitative mixed method design, this project has explored how the use of quality indicators to govern the municipal health and care services shapes the services from within, from the level of staff-service user interactions to the level of management and policy and back again. The project has advanced our understanding of the pros and cons of quality indicator management and thus improved the validity of the knowledge base around locally reported data and its use in governance, management and service decision purposes. The project has also formulated policy-recommendations about quality management improvement and how to ensure the importance of service activity that is not made visible by the measures, informed by active user involvement.

Our ambition at the start of MASQ was that our work on indicators would improve individual service delivery and managerial priorities within service units, generate knowledge for service planning, organization and policymaking, and produce data for health and care service analysis and research. In terms of impacts, we acknowledged that knowledge of quality indicator systems in context could influence multiple societal and organizational processes, to benefit the service users and the work situation of the health and care service personnel. Accordingly, active user involvement throughout the project sought to maximize positive outcomes for targeted user groups, also enabled by MASQ’s active dissemination plan. In terms of achieved impact, the active integration of user involvement through the entire project period has sought to maximize the possible impacts for all the targeted user groups (increased reflexivity and knowledge about quality indicator use and their roles in quality improvement municipal health and care services). Although we have not systematically monitored the extent to which project outputs have been put to use, frequent and active user inclusion through the project, recurring participation and sustained interest from multiple actors in the project’s dialogue events and final recommendations, and informal feedback about usefulness and relevancy of these events and outputs, all indicate successful impact via target groups’ uptake and learning, via project activities. In addition, the project’s active dissemination has secured a potential for outcome that reach far broader than the municipalities and individuals that we have had primary dialogue and cooperation with. The PhD thesis due for completion shortly after the end of the project period has been and continues to be the subject of dissemination by Centre for Care Research Norway, including via involved municipalities and through local newspapers. The forthcoming scientific anthology similarly will be publicized by project participants as well as by its publisher, Scandinavian Academic Press. Sustained relationships have been formed with project user partners including quality advisors in the Norwegian Health Platform, forming an additional basis for further dissemination and follow-on collaborations and projects in the future. Policy-recommendations have been shared with a wide range of audiences including national authorities, and as mentioned above the national Health library operated by the Norwegian Institute of Public Health is in the process of publicizing MASQ recommendations to relevant audiences across Norwegian municipalities – such dissemination has and will continue to be accompanied by social media and other forms of dissemination by NTNU Social Research and other project partners, after the project’s completion. Taken together, the above on-going efforts continue to stimulate MASQ’s impacts beyond the project period.

Norwegian municipal health and care services have become increasingly complex to organize, manage and work within, due to range of political, health and care professional and demographic factors. The more complex a service becomes, the more complex is also the quality management of the service. A preferred tool to solve this puzzle has been to introduce performance and quality indicator systems. A national quality indicator system for the Norwegian municipal health and care sector has recently been established. Larger municipalities have developed and publish online data from local indicator systems for their own services, and use the data also for service monitoring, planning and budgeting. Still, national authorities request more and better quality indicators in the services and more research on the quality of the services to extend the limited knowledge basis that indicators and professional guidelines are developed from. Current development work with indicators is often based on a too narrow approach to quality. MASQ addresses this lack of perspectives and the gap in knowledge between political ambitions and practice with a comparative mixed-method study of quality management in municipal health and care services, with a special focus on use and effects of quality indicators for the services and how they shape the work of the services' street level bureaucracy. MASQ will study the national quality indicator system for the Norwegian municipal health and care sector and locally developed quality indicator systems in at least 10-15 municipalities. Indicator (non-)use is very variable. Data will be collected along horizontal and vertical axes in the Norwegian municipal health and care sector, from national policy to municipal top- and middle- management and municipal health and care delivery, and inter-municipal cooperations, and from different services (nursing homes, care for people with intellectual disabilities, home care services and local mental health care).