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Implementation strategies influence the structure, process and outcome of quality systems: an empirical study of hospital departments in Sweden
  1. S Kunkel,
  2. U Rosenqvist,
  3. R Westerling
  1. Department of Public Health and Caring Sciences, Uppsala University, Sweden
  1. Dr S Kunkel, Department of Public Health and Caring Sciences, Uppsala Science Park, SE-751 85 Uppsala, Sweden; stefan.kunkel{at}


Objective: To analyse whether the organisation of quality systems (structure, process, and outcome) is related to how these systems were implemented (implementation prerequisites, cooperation between managers and staff, and source of initiative).

Methods: A questionnaire was developed, piloted and distributed to 600 hospital departments. Questions were included to reflect implementation prerequisites (adequate resources, competence, problem-solving capacity and high expectations), cooperative implementation, source of initiative (manager, staff and purchaser), structure (resources and administration), process (culture and cooperation) and outcome (goal evaluation and competence development). The adjusted response rate was 75%. Construct validity and reliability was assessed by confirmatory factor analysis, and Cronbach alpha scores were calculated. The relationships among the variables were analysed with structural equation modelling with LISREL.

Results: Implementation prerequisites were highly related to structure (0.51) and process (0.33). Cooperative implementation was associated with process (0.26) and outcome (0.34). High manager initiative was related to structure (0.19) and process (0.17). The numbers in parentheses can be interpreted as correlations. Construct validity was good, and reliability was excellent for all factors (Cronbach alpha>0.78). The model was a good representation of reality (model fit p value = 0.082).

Conclusions: The implementation of organisationally demanding quality systems may require managers to direct and lead the process while assuring that their staff get opportunities to contribute to the planning and designing of the new system. This would correspond to a cooperative implementation strategy rather than to top-down or bottom-up strategies. The results of this study could be used to adjust implementation processes.

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  • Competing interests: None.