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

In decades, public governance has aimed for increased quality and efficiency of the Norwegian municipal health and care services. This is an undisputed goal. All stakeholders want high quality service delivery. Yet, what quality is, is difficult to define. And efforts to create quality - through reforms, increased health and care expertise demands, preparations for a demographic aging of society, and so on ? has brought with it a paradox: The more complex a sector becomes, the more complex becomes the task of uniting on a quality concept as well. A preferred tool in governance and management for solving this puzzle has been to introduce performance and quality indicator systems for control and transparency purposes. The municipal health and care services are no exception. Yet, unintended effects of such systems are documented in earlier organizational research. For instance, they suggest that a standardization of service delivery may take place, and changes in awareness of which work tasks that matter the most among management and health and care personnel cay be anticipated. As a well-known slogan says, what is measured is what counts. Through a qualitative mixed method design, this project explores 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 will advance the understanding of the pros and cons of quality indicator management and improve the validity of the knowledge base that are produced by the locally reported data and used for governance, managerial and service decision purposes. The project will also provide policy-recommendations about quality management improvement and how to ensure the importance of service activity that is not made visible by the measures - and implement consequences of this advanced knowledge into the services through active user involvement.

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).