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

Spørsmålet om hvordan øke kvalitet og effektivitet i kommunal helse- og omsorgssektor er like gammelt som sektoren selv. Alle ønsker høy kvalitet. Men hva kvalitet er, og hvordan oppnå dette, er ikke entydig. Arbeid for kvalitetsheving, gjennom reformer, økte kompetansekrav, forberedelser til eldrebølgen og så videre, aktualiserer dessuten et paradoks: Jo mer kompleks sektoren blir, desto vanskeligere blir det å definere og sikre kvalitet. Et foretrukket grep i styring og ledelse for å løse paradokset har vært å introdusere målstyring og verktøy som kvalitetsindikatorsystemer, for kontroll og transparens. Kommunale helse- og omsorgstjenester er intet unntak. Ikke-intenderte effekter av slike system er bredt dokumentert i organisasjonsforskning. Her foreslås blant annet at grepet medfører standardisering av tjenestene, og at tjenesteansatte endrer prioriteringen av arbeidsoppgaver som ikke nødvendigvis gagner dem de jobber for. Det som teller er det som måles. Dette prosjektet har studert hvordan bruken av kvalitetsindikatorer for å styre de kommunale helse- og omsorgstjenestene former tjenestene fra innsiden. Prosjektet har benyttet et kvalitativt metodedesign, hvor forskerne følger kvalitetsindikatorene «gjennom tjenestene», fra de lages og rapporteres til de blir virksomme data og beslutningsgrunnlag for tjenestene. Med andre ord har vi studert måling av kvalitet, kvalitetsforbedrende praksiser og indikatorbruk i tjenestene, fra samspillet mellom personell og tjenestebrukere til ledelsesnivå og politikkutforming, og tilbake til «bakkenivå». Prosjektet har således utviklet forståelsen av kvalitetsindikator-styring, for å øke validiteten til kunnskapsbasen om tjenestene som aggregeres opp av lokalt rapporterte data. Prosjektet har utviklet policy-anbefalinger for hvordan forbedre kvalitetsstyring. Prosjektet har vært et samarbeid mellom NTNU, NTNU Samfunnsforskning, Senter for omsorgsforskning Gjøvik, Amsterdam University Medical Center, norske kommuner og brukerorganisasjoner.

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).