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Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems
Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway.
Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway.
Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway.
Imperial College, London, St Mary’s Campus, Norfolk Place, London W2 1PG, UK.
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2014 (English)In: BMC Health Services Research, ISSN 1472-6963, Vol. 14, no 478, 1-12 p.Article in journal (Refereed) Published
Abstract [en]


Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study.


This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics).


The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided.


The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

Place, publisher, year, edition, pages
2014. Vol. 14, no 478, 1-12 p.
Keyword [en]
Quality conceptualization; Clinical effectiveness; Patient safety; Patient experience; Multi-level case study; Quality improvement
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
URN: urn:nbn:se:hj:diva-25636DOI: 10.1186/1472-6963-14-478PubMedID: 25303933Local ID: HHJKvalitetISOAI: diva2:780475
EU, FP7, Seventh Framework Programme

This study is part of the EU FP7 project Quality and Safety in European Union Hospitals (QUASER)

Available from: 2015-01-14 Created: 2015-01-14 Last updated: 2015-01-14Bibliographically approved

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