Journal of Health Organization and Management

Quality improvement in large healthcare organizations: Searching for system-wide

and coherent monitoring and follow-up strategies
Elisabet Höög Jack Lysholm Rickard Garvare Lars Weinehall Monica Elisabeth Nyström
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Elisabet Höög Jack Lysholm Rickard Garvare Lars Weinehall Monica Elisabeth Nyström ,
(2016),"Quality improvement in large healthcare organizations", Journal of Health Organization and
Management, Vol. 30 Iss 1 pp. 133 - 153
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Quality improvement in large QI in large

healthcare
healthcare organizations organizations

Searching for system-wide and coherent

monitoring and follow-up strategies 133
Elisabet Höög Received 18 July 2013
Department of Public Health and Clinical Medicine, Revised 7 October 2013
21 July 2014
Epidemiology and Global Health, Umeå University, Umeå, Sweden and 5 September 2014
Department of Learning, Informatics, Management and Ethics, Accepted 6 September 2014
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Medical Management Centre, Karolinska Institutet, Stockholm, Sweden

Jack Lysholm
Department of Surgery and Perioperative Sciences,
Umeå University, Umeå, Sweden
Rickard Garvare
Department of Business Administration, Technology and Social Sciences,
Luleå University of Technology, Luleå, Sweden
Lars Weinehall
Department of Public Health and Clinical Medicine,
Epidemiology and Global Health, Umeå University, Umeå, Sweden, and
Monica Elisabeth Nyström
Department of Learning, Informatics, Management and Ethics,
Medical Management Centre, Karolinska Institutet, Stockholm, Sweden

Abstract
Purpose – The purpose of this paper is to investigate the obstacles and challenges associated with
organizational monitoring and follow-up (M&F) processes related to health care quality improvement
(QI) and development.
Design/methodology/approach – A longitudinal case study of a large health care organization
during a system-wide QI intervention. Content analysis was conducted of repeated interviews with key
actors and archival data collected over a period of four years.
Findings – The demand for improved M&F strategies, and what and how to monitor were described
by the respondents. Obstacles and challenges for achieving M&F strategies that enables system-wide
and coherent development were found in three areas: monitoring, processing, and feedback and
communication. Also overarching challenges were found.
Practical implications – A model of important aspects of M&F systems is presented that can be
used for analysis and planning and contribute to shared cognition of such systems. Approaches for
systematic analysis and follow-up of identified problems have to be developed and fully incorporated
in the organization’s measurement systems. A systematic M&F needs analytic and process-oriented
competence, and this study highlights the potential in an organizational function with capacity and
mandate for such tasks.

Journal of Health Organization and

Management
Vol. 30 No. 1, 2016
This study was mainly funded by the Vinnvård research program in Sweden (project A2007034), pp. 133-153
with contributions from the Strategic Research Programme in Care Sciences at Karolinska © Emerald Group Publishing Limited
1477-7266
Institutet and Umeå University, funded by the Swedish Research Council. DOI 10.1108/JHOM-10-2013-0209
 JHOM Originality/value – Most health care systems are flooded with a vast amount of registers, records,
and measurements. A key issue is how such data can be processed and refined to reflect the needs and
30,1 the development process of the health care system and how rich data can be used for improvement
purposes. This study presents key organizational actor’s view on important factors to consider when
building a coherent organizational M&F strategy.
Keywords Change management, Quality improvement, Organizational development,
Monitoring and follow-up
134 Paper type Research paper

Introduction
Demands for more, better, and safer health care seem to increase indefinitely, and
worries that resources do not meet needs are frequently presented (Davies et al., 2013).
Consequently, high expectations are linked to quality improvement (QI) and change
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interventions in health care settings to address these needs and demands. At the
same time, achieving successful QI in health care is an on-going struggle (Grol, 2001;
Grol et al., 2007). Numerous tools and interventions have been suggested for achieving
QI and many trends have come and gone (Chassin and Loeb, 2011; Walshe, 2009).
David Kernick (2006) identified a need for new methodologies in health services
research in order to better address how complex health care organizations can improve
their services, including “better tools that promote systematic thinking and that are
accessible to those who actually deliver health care” (p. 390).
Many factors believed to influence the results of QI interventions have been studied,
for example, the characteristics of the intervention (Greenhalgh et al., 2004), the varying
degree of readiness for change within the organization (Caldwell et al., 2008), and
contextual influences such as the organizational setting, the environment, and the
individual (Kaplan et al., 2010, 2012; Nyström, 2009). Implementing QI initiatives that
are both coherent and adaptable in a context where conditions change over time
requires a broad and accurate understanding of needs, opportunities, processes, and
results (Chassin and Loeb, 2011). Monitoring in organizations provides a basis for
knowledge (Nicolini et al., 2007), but how to best manage the knowledge gathered to
support QI in health care still needs to be explored (Graham et al., 2006; Guilfoyle, 2012;
Oliver, 2009; Rashman et al., 2009). Many attempts to build comprehensive models for
organizational QI have been made (Kennedy et al., 2011), but there is at present no
consensus on how a merging of monitoring and follow-up (M&F) information should be
utilized. Clinical governance (Braithwaite and Travaglia, 2008; Greenfield et al., 2010;
Sweeney and Mannion, 2002) and clinical audit (Bowie et al., 2012) are two follow-up
approaches with a potential to strengthen QI initiatives.
The importance of a continuous monitoring and systematic follow-up of
organizational results as well as processes that mirror the interlaced conditions of
health care have been noted in previous studies (Benn et al., 2009; French et al., 2009).
Because resources are usually scarce and prioritization is essential in health care, this
often requires measuring and evaluating health outcomes and treatment effectiveness,
as well as financial and personnel conditions and results (Goldfield et al., 2012). The
balanced scorecard approach (Kaplan and Norton, 1996a, b) is one attempt to construct
a strategic control system linking goals on several levels to overall organizational
strategy by using measurements and indicators of the financial, customer, internal-
business-process and learning and growth perspectives. The balanced scorecard
approach connects non-financial and financial measures and is often used in private
for-profit firms. The approach has been criticized for its assumptions, for example,
 regarding customer satisfaction which does not necessarily produce good financial QI in large
results (Norreklit, 2000) and the financial calculus involved (e.g. choices of most healthcare
profitable products or customers), the latter might not be as suitable for health care.
The importance of coherence among the chosen strategic areas and between resources
organizations
and performance measures have also been highlighted (e.g. Buschor, 2013; Collis and
Montgomery, 1997; de Haas and Kleingeld, 1999). Achieving a well-functioning follow-
up and feedback system requires adequate resources, methods, and competence 135
(Crawford and Nahmias, 2010), and the necessary diligence to obtain continuous
monitoring and systematic QI has to permeate the organization from the operational
level to the top management (Goeschel et al., 2011; Langley and Denis, 2011).
Most health care systems are flooded with a vast amount of registers, records, and
measurements (Lazar et al., 2013). A key issue is how such data can be processed and
refined to reflect the needs and development of the health care system and how rich
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data can be used for improvement purposes (Derose et al., 2002; van de Veer et al., 2010).
In a complex setting, timely access to information is vital for enhancing change
processes and the importance of measuring and evaluating QI initiatives and their
results is well documented (Hulscher et al., 2003; Mainz, 2003; Walshe and Freeman,
2002). Even so, there seem to be few clear answers on how to use the follow-up
information or how the knowledge should be merged with other core organizational
control and follow-up systems. Another issue is how to use these data in strategic
planning and decision making (Arah et al., 2003; Sadeghi et al., 2013). How health care
organizations cope with the complexity and magnitude of multi-dimensional M&F
strategies is a question of their ability to build dynamic capability where “it must
systematically record and track the results of its repeated cycles of knowledge
creation” (Anand et al., 2009, p. 455).
The purpose of this study was to investigate the obstacles and challenges associated
with M&F processes related to organizational development and QI. By doing so, we
hope to contribute to the understanding of conditions necessary for coherent M&F
strategies in health care organizations, implementing system-wide QI interventions. We
use the term “M&F” throughout this paper. By this we mean the processes and
activities aimed at obtaining knowledge and understanding of organizational
operations and processes such as measurements, analyses, and decision making. We
have taken a particular interest in systems and strategies related to QI, change, and
development. This study wishes to provide input to further research as well as to
practitioners involved in developing strategies for organizational M&F in health care.
The empirical case chosen for this work was a health care organization studied during
a time when a system-wide QI intervention was launched.
The following more specific research questions were addressed:
RQ1. What were the main focus areas for M&F in the studied health care system?
RQ2. What were the perceived obstacles and challenges to achieving a system-wide
and coherent M&F system for enhancing QI?
RQ3. How did organizational actors’ perceptions of obstacles and challenges for
M&F strategies change over time as the system-wide QI intervention evolved?
The empirical case
The empirical case was a health care provider organization for specialized inpatient
and outpatient health care in one of Sweden’s 21 regions managed by county councils.
The county council is an organization led by politicians with the main task of providing
 JHOM health care and public health work. In this county council, specialized health care
30,1 was provided at three hospitals, one of these was a university hospital. In addition to
the political level the organization had two principal decision-making levels, the
department managers and the county director’s office, and the respondents in this
study came from both of these levels. There are county council regulations for the
allocation of responsibility between politicians and officials whereby politicians
136 control health care by setting goals and pointing out directions for the county council.
Decisions are implemented via plans of operation that set boundaries of the
undertaking, usually with focus on financial issues (Anell, 2005). Another part of
the political guidance is to follow-up on the health care objectives and activities, as well
as the needs of the citizens.
In 2007, it was decided to initiate a system-wide change to create a structure that
would enhance QI (see Figure 1). The initiative included the integration of formal M&F
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systems with on-going development processes. The intervention was named “The
Dynamic and Viable Organization” (DVO). The system change had formal support
from top management levels and implementation support from the county councils
internal development unit. The intervention aimed to build a structure of meetings,
forums, groups, and communication channels to facilitate system-wide and coherent QI
(Nyström et al., 2012, 2014).
The specialized health care departments varied in size and location, where the
largest departments consisted of several sub-units, sometimes located at all three
hospitals. Development groups were formed in each specialized health care department
and were responsible for the overall QI initiatives at the department level. The hands-
on development initiatives were led by improvement teams, including representatives
from the staff and the departments’ management teams. The improvement teams were
encouraged to work according to PDSA principles (Langley et al., 2009), including an
emphasis on tests and measurements. The intervention also included the formation of a
strategic coordination team (SC team) with representatives from top-level management,
clinical (department) management, an intra-organizational development unit, and other
office functionaries. The development unit was part of the strategic organizational level

Formal organizational structure Process structure - DVO

Top level
management and offices Strategic Coordination
Team
including an intra-organizational development unit

Strategic Forums
Specialized Health Care
management and offices

Development Groups

Figure 1. Department and sub-unit

Model of management
organizational Learning Seminars
structure and
its representation in
the process
Department and sub-unit staff Improvement Teams
structure of DVO
 but had a rather independent and both advisory and hands-on mission to support QI in large
development within the organization. The SC team, the development groups, and the healthcare
top-level management met regularly, two to three times a year, in “Strategic Forums” in
which experiences were shared and the results of QI initiatives at different levels of the
organizations
organization were reported. Improvement teams and development groups could also
meet in “Learning Seminars” aiming at knowledge building and the sharing of
experiences and good examples. 137
A template for monthly reports was developed and an internet-based
communication board system accommodated by the Swedish Association of Local
Authorities and Regions was used to collect and share measurements and results
between all teams and groups involved in the intervention. The internal development
unit was a resource intended mainly for the development teams and was also
responsible for leading the activities during the Strategic Forums.
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Method
This case study used a longitudinal design (Kohlbacher, 2005; Yin, 2009) and was part
of a larger research project that investigated the implementation of DVO in specialized
health care from 2008 to 2012. The DVO case has provided an empirical basis for
several studies (Höög, 2014; Nyström et al., 2012, 2014; Westerlund et al., 2015)
including the opportunity to explore the perception of higher management levels and
officials of M&F processes during development of QI strategies.

Data collection
The study focussed on the experiences of intra-organizational change facilitators as
well as top- and mid-level managers. Data consisted of repeated interviews and archival
data, collected from 2008 to 2011, with interviews performed by members of the
research project (EH, MN, and a research assistant) during the implementation phase
(2008-2010) and the establishment phase (2010-2011).
In total, 17 respondents from top management, the county council’s strategic
planning office, and the development unit participated in the study. In total,
27 semi-structured interviews (Bouchard, 1976; Flick, 2014) were conducted and
distributed during the implementation phase (15 interviews) and establishment phase
(12 interviews) of the DVO intervention. The interviews lasted between 30 and
60 minutes and were recorded and transcribed verbatim. The starting point for all
interviews was organizational change, improvement, and development. The main
themes for the interview questions concerned: strategies, planning, and management of
M&F; the follow-up focus and its content and targets; and the follow-up of effects and
consequences. The interviews were semi-structured for the aim of achieving answers
rich in detail. The basic form was open unvalued question→reinforcement of open
question if needed→follow up questions to test hypothesis and capture
perspectives→summary. Archival data consisted of the minutes from the DVO
coordination team meetings (13 documents), general DVO information, and agendas
from the DVO forums (seven documents).

Data analysis
Analysis of the interview data was performed iteratively with inductive category
development followed by deductive category application. This rule-guided and
systematic text analysis approach is discussed by Mayring (2000, 2007) who stresses
 JHOM the benefits of using the methodological strengths of quantitative content analysis in
30,1 the process of analyzing qualitative data. Directed content analysis (Hsieh and
Shannon, 2005) was used with the archival data, and key concepts with operational
definitions based on the interview analysis were used when analyzing the documents.
The following analytical steps were taken for the interviews:
(1) For each interview, information was collected about whether the interview
138 covered the implementation phase or the establishment phase and the formal
role and organizational level of the respondent.
(2) Data were systematically searched to find content related to M&F.
(3) The main categories for what the M&F related data concerned, were identified.
(4) The main categories of obstacles and challenges were identified through an
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iterative process starting with a bottom-up categorization. When a

categorization scheme had emerged, the full interview material was classified
accordingly a second time, resulting in main categories and sub categories.
Archival data were used to build the basis for the case description and to identify other
main interventions and activities that occurred during the studied period. Documents
related to the DVO intervention (SC team minutes and Strategic Forum agendas) were
classified according to steps 2-4 above. The documents were judged according to
whether or not they contained each category.

Results
The result section begins with a contextual overview and is thereafter structured in line
with the three research questions, starting with the main focus areas for M&F,
reflecting the key actors’ views on what to monitor and follow-up in times of change
and development. Thereafter the perceived obstacles and challenges for achieving a
system-wide and coherent M&F system are presented, including changes in actors’
views over time.

Major events in case context during the study period

The studied organization operated in a dynamic and demanding internal and external
context with numerous national, regional, and local control signals to respond to.
Archival data showed major events and activities during the studied period that occurred
in parallel to the implementation and establishment of DVO (Figure 2). Some of the most
important events and activities during the studied period were a system-wide, two-step
process involving self-evaluation of departmental activities and results to be used as a
basis for financial and operational prioritizations; a national initiative on how to use
measurements in organizational decision making, in which several key actors from the
SC team participated; a major outbreak of pandemic flu that demanded resources and
extraordinary actions and activities; an up-coming shift in top management; and the
introduction of Lean production methods for some departments that involved local- and
national-level activities by the internal development unit. All of these activities mirror a
complex environment with a mix of planned and uncontrolled changes and events.
All respondents in this study were actively involved in the DVO intervention.
They were also holders of support or managerial positions implying a responsibility
for, or involvement in, the events presented in Figure 2. The interviews captured actor
views in an organizational context during the implementation and establishment of the
DVO intervention.
 Internal organizational initiatives QI in large
DVO - Implementation phase (IP)
healthcare
DVO - Establishment phase (EP)
organizations
Prioritizing processes

National initiatives
Measure to lead
139
Contextual influences
Pandemic flue outbreak Figure 2.
Top management changes An overview of
major events that
Introduction of Lean
affected specialized
health care during
the studied period
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2008 2009 2010 2011

Core areas for M&F

The analysis revealed a range of areas related to M&F in a broad sense. The areas
identified were similar to those of other open system models, including objectives,
interventions and activities, processes and outcome. Data were classified into these four
main categories (see Figure 3), containing both intervention specific aspects and more
general organizational issues.

Vision and objectives

The first category, labeled vision and objectives was the least covered category by
respondents. This category included M&F of organizational goals and visions as well
as more intervention specific objectives. Overall the category statements were
formulated in general terms. Some respondents highlighted conflicting goals, such as
financial plans and care operation goals. Business plans on all levels were identified as
important but somewhat underused for the M&F processes in a QI perspective. The
studied organization had a system-wide vision concerning health outcomes. The vision
was recognized, but not identified as something that was included in an M&F system.
Organizational goals and visions were considered to be set by politicians, and the
respondents expressed a misgiving that politicians had limited knowledge of on-going
activities and the realities of everyday business:
But we have no comprehensive evaluation plan, but we are supposed to measure and report to
the politicians how we work towards those goals that they have set up. And that is the
council’s objectives – good, safe and equal care and so. And there, we have our metrics that we
deliver and that goes into the annual and interim reports (Top management).

Areas identified as important to monitor and follow-up

(1) Vision / Objectives

Figure 3.
(2) Intervention (3) Learning and change (4) Medical and Core areas for M&F
organizational outcomes
activities processes
processes – what to
Core organizational operations monitor and
follow-up
 JHOM There are still areas where it is very difficult to find good monitoring parameters and some of
the goals of the county plan is pretty bushy […] or vague. I mean, good and equal care is of
30,1 course […] very long-term, visionary goals (Top management).
Then the politicians want to see results. They want to be able to read the results in terms of
improved access and high patient safety and so. How we then work with it, they (the
politicians) are not so involved in (Top management).
140
Intervention activities
The second category covered intervention activities, encompassing the on-going DVO
intervention as well as other interventions aiming at organizational development and
improvement. The statements on M&F of intervention activities were few, despite an
on-going system-wide intervention with many activities according to archival data:
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[…] the financial monitoring has been pretty hefty. There have been the result dialogues […]
and a special structure for development of the economy and how you follow the activity plans
that you set out. But when it comes to other areas, […] it has not been as structured and it
(information) has not been collected in the same systematic way as one might wish
(Top management).
[…] [M&F of intervention activities] Honestly, I do not know. But I feel I should be able to
answer that question (Top management).

Learning and change processes

The third category of areas for M&F was learning and change processes. This category
included processes at all levels, individual, group as well as organizational. It was seen
as important to be able to monitor and follow-up on all levels in order to see results of
interventions, as well as identifying obstacles and challenges for intended processes.
Other aspects included in this category concerned attitudes, culture, and approaches,
seen as important to identify and understand in the context of change. Changes in work
routines and practices were other aspects found to be important for M&F:
I can say today it is rare that someone says this, that – yes, we want to improve a single item,
paragraph. Almost all are adding – and then we would have to measure in order to monitor
how things went. And I can see, I think this is the direct result of that, by this process, this
culture change, that […] it is quite natural. Of course you have to check out how things go […]
to check the outcome for the patient is something everyone finds natural. That has always
been the case, but to check the process or the working arrangement have not been as natural.
So I think that it (measuring processes) is important (Top management).
I think it feels manageable somehow. It is not like to take a bite of the whole thing at once, you
become involved in the small attempts to actually take a step in the right direction, and then
you look at it. Was it good? Was it bad? Yes, this was great. Yes, then we expand the
development and so you share with others. Very simply put (Top management).
There are new indicators telling us other things, even though follow-up is still dominated by
economy and production. And this process orientation, well I think we are far away from that. We
do not even know what the processes are, then how can we measure them? (Development unit).

Health outcomes and organizational results

The fourth and last category included two aspects, health outcomes and organizational
results. This was the most emphasized category and the two aspects were so closely
interlinked that a separation of the category was not considered to be meaningful.
 Output and outcome of core care and administrative tasks was presented as the most QI in large
common and vital part of an M&F system and a control system involving both aspects healthcare
was under development in the organization:
organizations
M&F is pretty focused on economy and production. New quality parameters are under
development and so are health parameters, but is going very slowly (Development unit).

141
What to M&F – changes over time
The most highly emphasized areas for M&F identified by the respondents during the
implementation phase were medical and organizational outcomes and learning and
change processes (see Figure 4). For the establishment phase, the proportions of
interviews emphasizing each area increased. In this phase, all interviewees recognized
medical and organizational outcomes followed closely by learning and change processes.
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Identified areas with obstacles and challenges for M&F processes

Data were analyzed in order to find obstacles and challenges related to M&F processes
over time. Obstacles were defined as explicit descriptions of difficulties and problems, the
definition of challenges was statements on fears and misgivings as well as possible
opportunities. Three separate but interrelated areas containing obstacles and challenges
were identified: (A) Monitoring, (B) Processing, and (C) Feedback (see Figure 5).

Components of QI context Implementation phase (n:15) Establishment phase (n:12)

Vision / Objectives 33% 58%
Intervention activities 47% 67%
Learning and change processes 67% 83%
Medical and organizational outcomes 60% 100%
100%
Implementation phase (n:15)
Establishment phase (n:12)
75%

50%

Figure 4.
25%
Proportion of
interviews covering
0%
the core areas
Vision / Objectives Intervention Learning and Medical and for M&F presented
activities change processes organizational by phases
outcomes

Areas with identified obstacles and challenges for monitoring and follow-up

(B) Processing
Figure 5.
Areas found to
include obstacles and
challenges for
monitoring and
(C) Feedback and
(A) Monitoring
communication follow-up
 JHOM Monitoring
30,1 The first area containing obstacles and challenges was Monitoring (A). Respondents were
discussing monitoring of everyday operations, overall organizational issues, as well as
specific aspects of the QI intervention. The monitoring was described mainly in terms of
regular and systematic control systems, covering a broad spectrum from financial issues
to health measurements but also as wishes and needs for further developed monitoring on
142 different organizational levels and of different perspectives and processes. Respondents
expressed that indicators and parameters used did not capture all the important factors,
especially not process-related aspects. The monitoring of on-going processes and
qualitative aspects viewed as important in QI processes, such as attitudes and learning,
lacked adequate and reliable indicators and measurement and did sparsely occur in the
present M&F system. Another challenge mentioned was the low frequency and defective
systematics of monitoring activities, resulting in poor knowledge and difficulties to follow
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processes and results over time. The coordination between different monitoring and
control systems was also discussed, as internal and external demands for documentation
and measurements were extensive. Respondents also questioned the reliability of the
organizational control systems, such as data accuracy and if there were enough
competence and capacity for measurements and monitoring throughout the organization:
You have to have a monitoring system that illustrates more than just the economy and the
production […] You have to see, have these indicators, in order to understand the problem in
reality. You need more rapid measurement systems and frequent measurements so that you
can find the root of the problem. Because if you only measure every six months so insanely
much can happen that can be the cause of the results (Development unit).
[…] sometimes we measure what we are able to measure, not always what we want to
measure. So it is a little bit about how we collect data. What systems do we use? What
reporting procedures do we use? (County council office).
I feel that the systems, you adjust the follow up (procedure) to what the systems can deliver
and I would like to have it the other way around. Adjusting systems to suit what you want to
observe. But it is also an investment. So it is a question of resources (County council office).
You need an M&F system that illustrates more than just economy and production. […] You
need indicators that make you understand the problems of reality (Top management).

Processing
The second area, Processing (B), concerned issues of compiling and analysis of
information and data, such as those discussed in the monitoring category. Respondents
reported that measuring and information gathering was to be carried out continuously,
and data to be sent to higher organizational office levels and to national authorities and
registers, (e.g. national quality registries). Respondents could not see that data and
information were analyzed and used for QI follow-up and development purposes.
Obstacles and challenges identified were not only the vast amount of data, but also the
complexity of information that made aggregation and analysis difficult in terms of time
needed to process them. A lack of competence, knowledge and skills for more overall
and complex processing procedures was also identified, as was the sheer lack of data
on qualitative aspects and overall perspectives:
I think there is a risk that we are drowning in ambition to follow up, but also drowning in the
amount of potential data that we have to take care of and analyze. So, I think we need to get
better at finding the right follow-up parameters, to sort a little better and make it easier for
 units and departments, in order to make it (measurements) more interesting and more QI in large
accessible (Top management).
healthcare
Sometimes we feel almost confused over the large amount of data, although important, organizations
informative and valuable, we still do not grasp how to use it (Top management).
The hindrance is more than prioritizing of the task, put time aside and let other things go. It is
about making sure that there is competence available for the correct analysis. But that is the
situation for many of us, it happens easily that you stop at solving the “here and now” issues 143
(County council office).
In some cases we lack data but in many cases it is not the lack of data instead we do not have a
rational and structured organization to take care of data, transforming them into images, analyze
the images, make suggestions for changes and target levels and batter your way through the
system and ensure that decision are made, passed on and implemented (County council office).
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Feedback and communication

The third area comprised obstacles and challenges for (C) Feedback and communication
loops. This included issues on giving and receiving information as well as
opportunities for communication, discussion, and reflection upon follow-up results
and development needs. Main obstacles and challenges concerned established views,
attitudes, and practices of M&F processes. Respondents expressed an absence of
forums and forms for follow-up discussions and a lack of systematic approaches able to
satisfy the needs of different organization levels and complex follow-up issues. Another
obstacle for obtaining feedback and communication loops was the lack of a clearly
communicated purpose for such loops:
I think of feedback loops, then, there are indications from the context but maybe also information
via public performance or something. The signals are […] not captured as a learning experience.
What have we learned from this, and how can we avoid that it reoccur? The structure of the
monitoring is not in place. But […] I think we are getting there (Development unit).
A feedback system that develops the mental model of what we want to accomplish, I think
that is important. A monitoring and feedback system, forums, etc., leadership, involvement in
such a way that contribution make you understand what is happening. And something you
can act on – that I also think is important. You need to be involved in such a way that people
understand why you achieve a given effect (Development unit).
We need immediate feedback. We tried this – this is how it turned out. And that feedback
should not only stay in the group, but be communicated so those who handle the overall
perspective get aware of what happen when we try things in, in reality. And by that maybe
they will adjust their overall intentions (Top management).

Obstacles and challenges for M&F processes – changes over time

The most emphasized category of perceived challenges and obstacles in both phases
was processing (Figure 6). Almost all the interviews from the establishment phase
recognized the three challenge categories and the proportions had all increased
compared to the implementation phase.

Overarching obstacles and challenges related to an M&F system

The analysis also revealed an additional pattern of overarching obstacles and challenges
concerning issues on how to structure and manage M&F processes. These more general
obstacles and challenges concerned M&F from a more strategic and organizational
 JHOM Challenge
Monitoring
Implementation phase (n:15)
53%
Establishment phase (n:12)
100%

30,1 Processing
Feedback
80%
67%
100%
92%
100%

75%

144
50%
Figure 6.
Proportion of
interviews covering 25%
areas with obstacles
and challenges for
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M&F processes 0%
presented by phases Monitoring Processing Feedback
Implementation phase (n:15) Establishment phase (n:12)

perspective and highlighted the interrelations between the identified areas; monitoring,
processing and communication and feedback. A main pattern of obstacles and challenges
concerned the role and function of organizational teams, groups, or functions with the
explicit responsibility for QI activities and the M&F of such interventions. This issue was
connected to strategic knowledge and competence on M&F systems in general, and M&F
as a basis for decision making in particular. The respondents also highlighted a lack of
formal structures to support the coordination of systematic organizational M&F and
enhance the endurance of such a system. How to manage M&F systems in complex
health organizations was perceived as particularly challenging:
From a management perspective, I think, you need to prioritize well. And then you have to be
sure to manage the improvement initiatives so that not all of our initiatives or a majority of
them will concern aspects that will have only a marginal effect (County council office).
My general impression is that we have partially parallel, partly nonexistent organizations, for
this. I mean, the monitoring of improvement, you assume first and foremost that there are set
target levels for the improvement work and that there is a strategic management team for
improvement initiatives and that it is part of a context. That someone has said – this we want
to achieve and that the same someone is interested to know if we did? And my impression is
that such a system is missing (County council office).
I perceive that we are not adequately organized to deal with issues that are not given in the basic
care process. Are they in the process we can handle them. Are they not, or in a border area it
immediately becomes more complicated. And if issues are outside of the personnel and finance
areas we also become lost. And that is because these are new aspects. That is, as I see it, a part of
knowledge management and this is a system that we are building now (County council office).
If you visualize a M&F system with a similar work approach on all organizational levels, based
on for them important indicators on them doing the right things in the right pace with good
quality and with good possibilities to follow-up, and if the all had a work approach that aims at
regularly discussing – not once a month or two time a year – but continuously, then I think, with
such a work approach, you would pick things up a lot quicker than today (Development unit).
The respondents further discussed these overarching issues, emphasizing a need for a
broad perspective on QI as a continuous and inherent entity of everyday business.
Questions were raised of what individual or function that could and would take on the
 strategic responsibilities to reflect on and act on findings from the follow-up system. QI in large
Furthermore, the management of what to monitor, and why, was discussed. With healthcare
references to the on-going intervention, the example of an SC team was seen as one
effort to address these challenges, but obstacles such as ambiguous roles, mandates,
organizations
and functions were considered to reduce the impact of such teams.
Other overarching issues included how to accomplish multi-dimensional monitoring
using both quantitative and qualitative indicators and how to cover such a complex 145
multitude of information and processes. Problems with coordinating control systems and
forming the basis for systematic evaluation of improvement needs were also highlighted.
The large amount of data and the complexity of data sets entailed processing challenges.
Linked to this, issues were raised about how, and to whom communication of results of
compiled data and analyses should be directed, and why. It was evident that the
management levels were conscious of these challenges and that actions were taken to
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solve problems, to learn, and to improve the process. Respondents also believed that no
single solution would solve the strategic issues of achieving systematic M&F of QI.

Results summarized in a preliminary model

The results illustrate a multitude of aspects of an M&F system, and describe obstacles and
challenges in several areas. A main concern seems to be about general and overarching
perspectives. The results are summarized in a model (Figure 7). The two boxes,

Areas with identified obstacles and challenges for monitoring and follow-up

(B) Processing

(A) Monitoring (C) Feedback and

communication

Overarching
Structure and management of obstacles and
monitoring and follow-up challenges

Areas identified as important to monitor and follow-up

1. Vision / Objectives

2. Intervention 3. Learning and change 4. Medical and

activities processes organizational outcomes

Core organizational operations

Figure 7.
Note: Including what needs to be monitored (1-4), parts of the system perceived as especially Overview of the
identified aspects of
challenging (A-C), and the obstacles and challenges related to the overarching structuring an M&F system
and management of the system
 JHOM representing results on what to follow-up and how to do it are connected by arrows,
30,1 representing the need for a constant flow and adjustment between the two main parts of
an M&F system.

Discussion
Health care systems are struggling to deliver high-quality services in times of scarce
146 resources and growing demands. Hopes are high on QI initiatives, but making QI
successful in health care organizations is still challenging. Walshe (2002, p. S46) wrote
that “quality improvement in health care demands leadership, investment,
perseverance, and hard work. There are no shortcuts to success.” This was reflected
throughout our study results. Every health care organization has to process issues on
what to follow-up and why, as well as how this can be co-ordinated. Thus, M&F can
and should be used strategically (Berwick et al., 2003; Cherney and Head, 2011; Sadeghi
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et al., 2013). The importance and value of M&F processes are well researched and
documented. In organizational settings this is often expressed in official documents as
well as colloquially. Still, what the follow-up processes really cover is not always
evident or clearly defined.
Systematic M&F need to be thoroughly developed to be able to capture intervention
aspects in an uncertain and complex environment (Perla et al., 2011; Prybutok and
Ramasesh, 2005). Our study reflects the views of key actors at managerial levels who
were all involved in an organization-wide QI intervention. The two main perspectives of
the M&F system – what and how to monitor – were covered in our results and many
obstacles and challenges were identified.
Statements on what to monitor and follow-up cover four main areas. The most
emphasized area was medical and organizational outcomes, which is a common area of
monitoring in health care organizations (Mainz, 2003). Learning and change processes
were also frequently highlighted, and difficulties in finding good indicators and
suitable methods for measuring them were identified, which confirms earlier research
results (Hulscher et al., 2003). Statements related to visions and objectives were less
frequently expressed. This result is somehow surprising as set goals and objectives
often are viewed as the core perspectives to follow-up in general, and as key
components for evaluating QI interventions and organizational development. The
follow-up of goals is often connected to evaluations at the end of a QI intervention and
might therefore be overseen during intensive implementation and establishment
phases. The result can also be partly explained by the perception of strategic visions
and objectives as something mainly initiated by political decision makers, and earlier
studies in Swedish settings found significant influence of policy-makers on what to
focus on when implementing QI initiatives (Elg et al., 2011). Few statements covered
M&F of intervention activities. Archive data showed that M&F was actually done of
specific activities within the main intervention, but the respondents did not give many
indications on that. This kind of M&F might have been carried out on unit level and
this information failed to reach the intervention management, or was not considered
important. Earlier research show that uncertainty of e.g. goals, role, and mandate could
hamper communication and necessary management overviews (Nyström et al., 2013).
The perceived obstacles and challenges to achieving a system-wide and coherent
M&F system for enhancing QI were found in three interrelated areas. Obstacles
and challenges of monitoring, concerning measurements, instruments, indicators, and
parameters, revealed a need and an urge for adequate and reliable indicators
and measurements of change and development processes in particular. Analysis of
 obstacles and challenges in the processing of data and results raised concerns QI in large
about organizational capacity to handle the large quantity and the complexity of healthcare
available and eligible data. Reflections on feedback and communication challenges
also highlighted the complications of having many organizational levels with
organizations
different needs and the difficulties in finding efficient channels for communication
between them.
The continuous interaction between “how” and “what” to monitor and follow-up 147
formed an overarching pattern with obstacles and challenges of its own. Concerns
about the demanding task of managing a follow-up system were raised, including
issues on knowledge and capacity, role issues, and organizational structure. What
became clear during the analysis were the overarching and general concerns about
system-wide and coherent aspects, not only between the four areas on how to monitor
and follow-up but also on the relation of these areas to what to monitor and follow-up.
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The respondents provided a practitioner’s view that was in line with earlier research
findings (Dilley et al., 2012; Höög et al., 2013).
The main issue seems to be about finding a coherent system-wide approach,
supported by organizational structures, distributed capacity, and teams or functions
with the assignment, role, and mandate to create a knowledge basis for overall
strategies. Such a system is also supported by previous research (Kislov et al., 2011,
2012; Walshe, 2007). An example of such a system-wide function identified in our case
was the SC team. The study results formed the basis for the construction of a
summarizing model of an M&F system that can support the understanding of how this
overview might be envisioned. The model (Figure 7) can aid managers and change
agents to foresee and keep track of challenges and thereby increase the possibility to
find obstacles and act on them at an early stage of development and change
interventions. A strategic function with the capacity and mandate to carry out
reflection and analyses is essential for building M&F strategies that enable sustainable
and coherent development. Any organizational system benefits from being advised on
what the most important aspects to monitor and follow-up on are for each specific
organization, why to do this, and how to do this (Harvey et al., 2011).

Limitations of the study

This case study covered a large health care organization in Sweden (i.e. a health care
region with three hospitals and many primary care units governed by elected regional
politicians). Longitudinal case studies using multiple methods have been proposed as a
way to study complex organizational phenomenon in health care (Benn et al., 2009), but
for generalization multiple cases are needed and the proposed model and identified
challenges might be used to compare cases. The key actors at various managerial levels
presented their views during a period of QI intervention activities. For future studies on
M&F systems in health care organizations, it would be advantageous to add data from
the political level in these public organizations because of their influence on and
responsibility for health care goals and financial resources. A closer study of the views
of, and documentation from, the development groups and improvement teams would
also have strengthened the results of this study.

Practical implications
This study presents two main areas that need to be addressed by research as well as
dealt with by practitioners: the importance of connecting everyday business and QI
 JHOM interventions, and the organizational capacity for M&F strategies and systems. We
30,1 present a model that can be used as a basis for analysis and planning of M&F systems
that can contribute to a shared cognition of such systems. In order to facilitate QI the
distribution and relevance of information seems to be of importance. Unbiased and
detailed data on operational performance, including problems and difficulties, are
central to enable improvement. It could be argued that high-performance M&F should
148 be an integrated part of the work with organizational vision and objectives, and that
the development of such systems can be coupled to incentives but never to blaming.
Approaches for systematic analysis and follow-up of identified problems need to be
developed and fully incorporated in the organization’s system for performance
measurement, e.g. balanced scorecards and other forms of multiple bottom lines.
Results indicate a great potential in using teams or functions with analytic and process-
oriented competence, capacity and mandate for SC of M&F in the organization.
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Conclusions
QI is a multifaceted phenomenon. Perspectives on improving health care range from
test and development in small frontline work groups using improvement knowledge
(Langley et al., 2009) to general organizational factors for diffusion of innovation
(Greenhalgh et al., 2004) or focus on the implementation of evidence-based practice
(e.g. Fixsen et al., 2005). Results presented in this paper show the importance of
acknowledging the need for a close inter-connection between QI and core
organizational activities and processes. Achieving coherence not only between
strategic areas as in the balanced scorecard approach (e.g. Norreklit, 2000), but
also between different organizational and social systems and organizational QI
competence seems important for successful results (e.g. McAlearney et al., 2013;
Nyström, 2009; Höög et al., 2013). Results also show that the management of strategic
and system-wide continuous development needs a reliable, accurate, and updated
knowledge base, not only on health outcomes and organizational results, but also on
processes, activities, and opinions. The study present obstacles and challenges
experienced in a case where such a system-wide intervention is on-going, illuminating
the potential of system-wide M&F structures but also a strong recognition of the need
for capacity and competence in handling such a system. In this paper we conclude that
a coherent M&F system could build a strong basis for QI in health care organizations.
This M&F system will have to include not only health care and organizational
outcomes but activities and processes in order to be used as decision support. Earlier
extensive research indicates that good QI aims for the right development areas at the
right time, in sync with other organizational activities and events. Such QI involves all
organizational levels and focusses on finding adequate forms and structures for
continuous and sustainable development in the organization. The studied organization
tried to build such an M&F system, using two team functions as hubs for the
intervention. Results indicate that these functions provided a promising solution to the
dilemma of coordinating QI in a complex organization, but they also strongly highlight
important prerequisites for these teams in terms of clear role and mandate, the need for
a broad range of competences and organizational perspectives as well as developed
communication strategies. The overview of the M&F system presented as a model in
Figure 7 could build the basis for analyzing existing or planning for development of
future M&F systems. It could also be used for further research on M&F systems and
their potential to support the management of short and powerful loops of knowledge
and development.
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About the authors
Elisabet Höög, PhD, is a Chief Research Assistant at the Epidemiology and Global Health,
Department of Public Health and Clinical Medicine at the Umeå University and a Research
153
Coordinator at the Medical Management Center, Department of Learning, Informatics,
Management and Ethics at the Karolinska Institutet, Stockholm, Sweden. Experienced
Organizational Consultant and Project Manager. Elisabet Höög is the corresponding author and
can be contacted at: elisabet.hoog@umu.se
Jack Lysholm, MD, PhD, is Head of the North Sweden Centre for National Quality. He is also
Professor Emeritus in Orthopaedics at Umeå University. North Sweden Centre for National
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Quality Registers supports organization and development of National Quality Registers. Other
main issues are models for data presentation, use of register data, and register based quality
improvement and research. Professor Lysholm is involved in research in injury epidemiology,
PROMS and implementation of new techniques in health care. He is also a Senior Advisor at
SALAR especially on register based research.
Rickard Garvare, PhD, is a Professor of Quality Management at the Department of Business
Administration, Technology and Social Sciences at the Luleå University of Technology, Sweden.
He has extensive experience of teaching a variety of courses in the master and doctoral programs.
Garvare’s present research efforts are focussed on operationalization, evaluation and control of
quality in public procurement and implementation of quality-related methodologies, in healthcare
organizations and systems.
Lars Weinehall is a Senior Professor of Epidemiology and Family Medicine and former Head
of Department of Public Health and Clinical Medicine at Umeå University, Sweden. Family
Physician by training. Was during 25 years coordinating the implementation of one of the
world’s largest on-going population-based intervention program for the prevention of
cardiovascular diseases (CVD) and diabetes, the Västerbotten Intervention Programme (VIP).
From 1994 full-time affiliated to Division of Epidemiology and Global Health, and largely
devoting his research to the role of primary care in population-oriented prevention. Has
supervised a number of PhD students, highlighting different aspects of CVD prevention, both
from Sweden, the USA, as well as from Indonesia and Vietnam. Is involved in health policy and
health system development research. Member of the Swedish Parliamentary Public Health
Commission 1997-2000. In 2008-2011 chairing the task force preparing National Board of Health
and Welfare’s National Guidelines for Evidence-Based Lifestyle Interventions in Clinical Practice.
Monica Elisabeth Nyström, PhD, Work and Organizational Psychology, is a Senior Lecturer
at the Medical Management Center, Department of Learning, Informatics, Management and
Ethics, Karolinska Institutet, Sweden. She also holds a Senior Position at the Department of
Public Health and Clinical Medicine Epidemiology and Global Health, Umeå University. She is the
leader of the research network SOLIID at Karolinska Institutet and Coordinator of the research
network with the same name. Her research focusses on development, change and learning in
complex Organizational Systems in health and social care.

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