Understanding staff perspectives of quality in practice in healthcare

Background: Extensive work has been focussed on developing and analysing different performance and quality measures in health services. However less has been published on how practitioners understand and assess performance and the quality of care in routine practice. This paper explores how health service staff understand and assess their own performance and quality of their day to day work. Asking staff how they knew they were doing a good job, it explored the values, motivations and behaviours of staff in relation to healthcare performance. The paper illustrates how staff perceptions of quality and performance are often based on different logics to the dominant notions of performance and quality embedded in current policy. Methods: Using grounded theory and qualitative, in-depth interviews this research studied how primary care staff understood and assessed their own performance and quality in everyday practice. 21 people were interviewed, comprising of health visitors, occupational therapists, managers, human resources staff and administrators. Analytic themes were developed using open and axial coding. Results: Diverse aspects of quality and performance in healthcare are rooted in differing organisational logics. Staff values and personal and professional standards are an essential element in understanding how quality is co-produced in everyday service interactions. Tensions can exist between patient centred, relational care and the pressures of efficiency and rationalisation. Conclusions: Understanding the perspectives of staff in relation to how quality in practice develops helps us to reflect on different mechanisms to manage quality. Quality in everyday practice relies upon staff values, motivations and behaviours and how staff interact with patients, putting both explicit and tacit knowledge into specific action. However organisational systems that manage quality often operate on the basis of rational measurement. These do not always incorporate the intangible, relational and tacit dimensions of care. Management models need to account for these relational and experiential aspects of care quality to support the prioritisation of patients' needs. Services management, knowledge management and ethics of care literature can provide stronger theoretical building blocks to understand how to manage quality in practice.