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Research article
A Qualitative Study of Organisational Response to National Quality Standards for 7-Day Services in English Hospitals
Julian Bion
University of Birmingham College of Medical and Dental Sciences
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0344-5403
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day service (7DS), from an organisational behaviour perspective.
Methods We conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response.
Results Senior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of Trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations.
Conclusions National standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by tailored support for improvement that takes into account local context and organisational culture.
Keywords
Organisational culture, Healthcare quality improvement, Qualitative research
Due to technical limitations, table 1 is only available as a download in the Supplemental Files section.
Table 2: Trust context and culture
|
TRUST |
NOTABLE FEATURES |
ORGANISATIONAL CULTURE |
FINANCIAL POSITION 2017-18 |
CQC QUALITY 2017-18 |
ORGANISATIONAL STRATEGY |
|
03 |
District general hospital in an urban location. 50% shortfall in consultant staffing in A&E and reliance on bank/agency staffing in AMU in particular. Well networked to other services in the locality. |
Hierarchical |
Reduced financial deficit but still had large deficit of over £20 million |
Requires Improvement |
This organisation focused on complying with the standards. Policies, processes and protocols were important in this hospital. They had implemented some changes by the introduction of more acute care physicians but there was the sense that more consultants were needed in order to deliver. |
|
07 |
Teaching hospital in an urban location in a deprived area. History of organisational turbulence as two separate organisations merged into one Trust a few years prior to fieldwork. Staff recruitment an issue in this Trust. |
Hierarchical / clan |
Agreed to deliver a deficit of no more than £35 million in 2018/19 |
Requires Improvement |
Focus on compliance with standards. A merger between two different hospitals had led to a more hierarchical approach in order to effect change. Over the past few years they had focused on recruiting new staff for the emergency pathway but were still exploring how staff could work differently. |
|
10 |
One hospital in a group of 3 in a relatively affluent urban area. Good links with other services in the locality. Recent change of board leadership; consultant body described as ‘the old fashioned firm structure’. |
Hierarchical / clan |
Had met their control total |
Good |
Focus on compliance with standards, use of audit to monitor. The hospital was reported to be hierarchical and reactive in implementing new policies and structures. The consultant body was reported to be ‘clannish’. Management were still working out where the gaps were in 7 day service targets. Changes to the consultant contract meant consultants were asked to conduct ward rounds at the weekend. |
|
11 |
District hospital. Staff recruitment difficult. The location was felt to be a deterrent as it was an expensive area to live in. Trust was in financial special measures at the start of the fieldwork. |
Hierarchical / clan |
£12 million deficit against a planned deficit of £7 million |
Requires improvement |
Commitment-based strategies. Organisation with a community feel, with stability and loyalty. Focus was on best interests of patients. Delivery was through incremental change and collaboration. |
|
12 |
Large teaching hospital and major trauma centre. Difficulties in recruiting to acute general medicine but not to specialist branches. |
Hierarchical / clan |
Deficit of over £8 million |
Good |
Focus on compliance with standards. There was seen to be a need for policies and procedures to maintain standards, and that innovations could be slow to implement and the organisation could suffer from micromanagement. New doctors were being told they would undertake acute medicine for 50% of the time and take part in the weekend rota, and contracts were short term. |
|
16 |
One of three hospitals supplying acute and maternity services located in a deprived area. Good links and access to the services supplied by the other Trusts. |
Developmental |
In surplus by over £7 million |
Good |
Commitment-based strategies. The focus was seen as being on the best interests of patients. This site used cooperative and collaborative strategies including peer pressure to achieve change. Management was heavily invested in achieving consensual change. |
|
17 |
Hospital in a rural location. Significant problems with staffing at all levels and a high number of locum consultants; great difficulties recruiting staff. A&E in nearby location closed in the evenings adding to pressure on acute services. Isolated from other services. |
Hierarchical / clan |
Financial special measures |
Requires Improvement |
Focus was on compliance with standards. The organisation was dealing with a legacy of poor performance and trying to instil good practice. There was a tension between encouraging innovation and controlling policies and procedures. The management did not have a specific plan or programme to meet the 7 day standards but were trying to use resources efficiently and centralise. They were working hard to recruit internationally, and improve the workforce with leadership programmes and centralise job plans. Yet there was a sense of great strain in this organisation. |
|
18 |
Large teaching hospital. Interviewees state that they have been meeting 7 day standards for some time. The hospital is well staffed. |
Developmental / rational |
In surplus by over £20 million |
Good |
Commitment-based strategies. This site framed changes in terms of best interests of patients. Change was being achieved through collaborative strategies including gaining consensus through participatory discussions with staff. |
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CURRENT STATUS: Under Review
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Posted 23 Sep, 2020
No community comments so far
Editorial decision: Major revision
On 09 Dec, 2020
Review #2 received
Received 05 Dec, 2020
Reviewer #2 agreed
On 04 Nov, 2020
Reviewer #1 agreed
On 16 Oct, 2020
Review #1 received
Received 16 Oct, 2020
Reviewers invited
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On 19 Sep, 2020
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On 19 Sep, 2020
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On 21 Aug, 2020
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This preprint is under consideration at BMC Health Services Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
A Qualitative Study of Organisational Response to National Quality Standards for 7-Day Services in English Hospitals
Julian Bion
University of Birmingham College of Medical and Dental Sciences
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0344-5403
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 23 Sep, 2020
No community comments so far
Editorial decision: Major revision
On 09 Dec, 2020
Review #2 received
Received 05 Dec, 2020
Reviewer #2 agreed
On 04 Nov, 2020
Reviewer #1 agreed
On 16 Oct, 2020
Review #1 received
Received 16 Oct, 2020
Reviewers invited
Invitations sent on 13 Oct, 2020
Editor assigned
On 20 Sep, 2020
Submission checks complete
On 19 Sep, 2020
Editor invited
On 19 Sep, 2020
First submitted
On 21 Aug, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day service (7DS), from an organisational behaviour perspective.
Methods We conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response.
Results Senior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of Trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations.
Conclusions National standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by tailored support for improvement that takes into account local context and organisational culture.
Due to technical limitations, table 1 is only available as a download in the Supplemental Files section.
Table 2: Trust context and culture
|
TRUST |
NOTABLE FEATURES |
ORGANISATIONAL CULTURE |
FINANCIAL POSITION 2017-18 |
CQC QUALITY 2017-18 |
ORGANISATIONAL STRATEGY |
|
03 |
District general hospital in an urban location. 50% shortfall in consultant staffing in A&E and reliance on bank/agency staffing in AMU in particular. Well networked to other services in the locality. |
Hierarchical |
Reduced financial deficit but still had large deficit of over £20 million |
Requires Improvement |
This organisation focused on complying with the standards. Policies, processes and protocols were important in this hospital. They had implemented some changes by the introduction of more acute care physicians but there was the sense that more consultants were needed in order to deliver. |
|
07 |
Teaching hospital in an urban location in a deprived area. History of organisational turbulence as two separate organisations merged into one Trust a few years prior to fieldwork. Staff recruitment an issue in this Trust. |
Hierarchical / clan |
Agreed to deliver a deficit of no more than £35 million in 2018/19 |
Requires Improvement |
Focus on compliance with standards. A merger between two different hospitals had led to a more hierarchical approach in order to effect change. Over the past few years they had focused on recruiting new staff for the emergency pathway but were still exploring how staff could work differently. |
|
10 |
One hospital in a group of 3 in a relatively affluent urban area. Good links with other services in the locality. Recent change of board leadership; consultant body described as ‘the old fashioned firm structure’. |
Hierarchical / clan |
Had met their control total |
Good |
Focus on compliance with standards, use of audit to monitor. The hospital was reported to be hierarchical and reactive in implementing new policies and structures. The consultant body was reported to be ‘clannish’. Management were still working out where the gaps were in 7 day service targets. Changes to the consultant contract meant consultants were asked to conduct ward rounds at the weekend. |
|
11 |
District hospital. Staff recruitment difficult. The location was felt to be a deterrent as it was an expensive area to live in. Trust was in financial special measures at the start of the fieldwork. |
Hierarchical / clan |
£12 million deficit against a planned deficit of £7 million |
Requires improvement |
Commitment-based strategies. Organisation with a community feel, with stability and loyalty. Focus was on best interests of patients. Delivery was through incremental change and collaboration. |
|
12 |
Large teaching hospital and major trauma centre. Difficulties in recruiting to acute general medicine but not to specialist branches. |
Hierarchical / clan |
Deficit of over £8 million |
Good |
Focus on compliance with standards. There was seen to be a need for policies and procedures to maintain standards, and that innovations could be slow to implement and the organisation could suffer from micromanagement. New doctors were being told they would undertake acute medicine for 50% of the time and take part in the weekend rota, and contracts were short term. |
|
16 |
One of three hospitals supplying acute and maternity services located in a deprived area. Good links and access to the services supplied by the other Trusts. |
Developmental |
In surplus by over £7 million |
Good |
Commitment-based strategies. The focus was seen as being on the best interests of patients. This site used cooperative and collaborative strategies including peer pressure to achieve change. Management was heavily invested in achieving consensual change. |
|
17 |
Hospital in a rural location. Significant problems with staffing at all levels and a high number of locum consultants; great difficulties recruiting staff. A&E in nearby location closed in the evenings adding to pressure on acute services. Isolated from other services. |
Hierarchical / clan |
Financial special measures |
Requires Improvement |
Focus was on compliance with standards. The organisation was dealing with a legacy of poor performance and trying to instil good practice. There was a tension between encouraging innovation and controlling policies and procedures. The management did not have a specific plan or programme to meet the 7 day standards but were trying to use resources efficiently and centralise. They were working hard to recruit internationally, and improve the workforce with leadership programmes and centralise job plans. Yet there was a sense of great strain in this organisation. |
|
18 |
Large teaching hospital. Interviewees state that they have been meeting 7 day standards for some time. The hospital is well staffed. |
Developmental / rational |
In surplus by over £20 million |
Good |
Commitment-based strategies. This site framed changes in terms of best interests of patients. Change was being achieved through collaborative strategies including gaining consensus through participatory discussions with staff. |