Charlotta Levay Caroline Waks Department of Business Studies Professions and the pursuit of transparency Two cases of professional involvement Presentation.

Charlotta LevayCaroline Waks

Department of Business Studies

Professions and the pursuit of transparencyTwo cases of professional involvement

Presentation at Royal Holloway, University of London

Centre for Public Services Organisations Seminar

Wednesday 14th November 2007

Dr Charlotta Levay, Research Fellow

Dr Caroline Waks, Assistant Professor

Uppsala University, Department of Business Studies



Today’s topics

Pursuit of transparency in healthcare

Research project at Uppsala University

Case study by Levay & Waks - accreditation and quality registries



Pursuit of transparency in healthcare

Increasing demands to make health care and quality differences visible to outside audiences

E.g. medical audits, accreditation, computerised medical records, rankings of hospitals or health care systems, etc.

• Consequence of NPM market creation

• Goes beyond NPM – new focus on medical effectiveness and democracy



Research project Uppsala University

Prof. Kerstin Sahlin, Dept of Business Studies Levay & Waks (eds.) 2006, Strävan efter transparens: Granskning, styrning och organisering i sjukvårdens nätverk [The pursuit of transparency: Audit, control and organisation in healthcare networks]. Blomgren 2007, ‘The drive for transparency: Organizational field transformations in Swedish healthcare’. Public Administration. Blomgren & Sahlin 2007, ‘Quests for transparency: signs of a new institutional era in the health care field’, in Transcending New Public Management, Christensen & Laegrid (eds.).



Transparency pursuits – a challenge to professional autonomy

Professions – occupational groups with a certain control of their own work; autonomy, self-regulation (Sarfatti Larson, Freidson, Abbott) Professional control of how the quality of work is evaluated Other/related challenges – state control; corporate control and standardization; New Public Management; economic logic in health care and public services Freidson – stratification of the professions



Professional response to transparency pursuits

Scepticism, worries for managerial colonisation of professional domains Resistance Decoupling

However Some transparency techniques developed by professionals Some studies show involvement and influence even after initial resistance



Study of professional involvement in transparency technologies

Purpose: To describe professional involvement in transparency techniques; to analyse how and why professionals get involved and the result in terms of professional autonomy Two qualitative case studies – semi-structured interviews, document studies and participation Quality registry case: Doctors; medical researchers and experts Accreditation case: Laboratory doctors, biomedical laboratory scientists, biomedical scientists



Some concepts to understand professional involvement

Soft regulation (Jacobsson, 2000; Mörth, 2004 ); soft bureaucracy (Courpasson, 2000)

Networks of professionals (Garpenby, 1999; Sheaff et al. 2003)

Translation – of ideas, models, standards (Czarniawska & Sevón, 1996, 2005; Sahlin-Andersson, 1996)



Two case studies

Levay (2006)

Swedish national quality registries 56 medical registries, e.g. National Diabetes Registry, Riks-Stroke Data on diagnoses, treatments, and outcomes Used to monitor and develop quality Voluntary participation, collegial organization Demands for public reporting

Waks (2006)

Accreditation at a medical hospital laboratory External scrutiny of work processes & documentation ‘Quality stamp’ and sales argument Established in Sweden following market creation Swedac – Swedish Board for Accreditation and Conformity Assessment Medical laboratory at a Swedish university hospital



Forms of involvement

Restraining forces

Driving forces

Results of involvement



Forms of involvement

Translation and negotiation

Network of professional experts and practitioners



Accreditation case Professionals involved in internal auditing, in preparing external assessments, and in assessing other laboratories Translation of general standards in local settings Negotiations between accreditor and accreditee Expert reference groups



You can be out at a lab and make an observation and wonder if it is a discrepancy and how we have done at other labs. How should we handle this? Much of what is in the standards are questions of interpretation. How should we interpret this? How should we assess it in a Swedish context? And then you can hand in a question to Swedac and you can hand in a question that is taken up in the assessment group.

Senior laboratory doctor and technical assessor



Quality registry case

Registries were started and operated by professionals

Translation of general standards and goals into specific measures; translation of medical measures into public information

Voluntary participation – collegial decision-making

Networks of experts and participant healthcare units



Whereupon I had a personal dialogue with the two department managers, and said that we would not start open reporting before everyone agreed about it. Then they accepted it, and we had the mandate to arrange open reporting.

Gynaecologist and manager of the National Quality Registry for Gynaecological Surgery



Restraining forces

Defending professional autonomy



Accreditation case

Initial resistance of laboratory doctors

Remaining critique regarding accreditation procedures, costs, and usefulness




Initial suspicion to registries as potential means of control

Reluctance to public quality comparisons



Forces driving involvement

Legitimising professional work

Developing professional work



Accreditation case

External legitimacy in relation to customers

Competitive advantage, then minimal requirement

Quality awareness, mutual learning, compatible with professional culture



[I]n this development, accreditation has made the degree of awareness of every step in the process, so that perhaps you think a little sharper about it. Especially that you need to reduce the risk of mistakes, there is a demand for traceability in a different way, a discussion that did not really occur earlier in the lab world. It is an awareness that is created in all development and accreditation is a contributing factor. It creates a way of thinking, so to say.

Biomedical laboratory scientists and quality coordinator for clinical chemistry




Originally a tool for developing professional knowledge and practice

Discovery of advantages with public reporting

Increased attention to registry data

Argument for new resources



My experience of the press corps is that you can make any number of mistakes, as long as you stand for it. [---] And poor those who have good results, they do not have as much use of the registry. It is those who have the worst results that have most use of it.

Gynaecologist and manager of the National Quality Registry for Gynecological Surgery



Results of involvement

Internalised transparency norms

Irreversible process

Professional control



Conclusion

Involved as professionals, not despite being professionals

Professional work made ‘auditable’ – with retained professional control

Charlotta Levay Caroline Waks Department of Business Studies Professions and the pursuit of transparency Two cases of professional involvement Presentation.

Documents

levay waks accreditation

dr charlotta levay

document studies

transparency techniques

abbott professional

democracy slide

quality registries slide

terms of professional