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Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service
  1. Lorelei Jones1,
  2. Linda Pomeroy2,
  3. Glenn Robert3,
  4. Susan Burnett4,
  5. Janet E Anderson3,
  6. Stephen Morris2,
  7. Estela Capelas Barbosa2,
  8. Naomi J Fulop2
  1. 1 School of Health Sciences, Bangor University, Bangor, UK
  2. 2 Department of Applied Health Research, University College London, London, UK
  3. 3 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
  4. 4 Centre for Patient Safety and Service Quality, Imperial College London, London, UK
  1. Correspondence to Dr Lorelei Jones, School of Health Sciences, Bangor University, Bangor LL57 2DG, UK; lorelei.jones{at}


Background Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.

Methods We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents.

Results Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of ‘slack’—expressed by participants as the ‘space to think’ and ‘someone to do the doing’—and the presence of a functioning board.

Conclusions Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

  • governance
  • quality improvement
  • organizational theory

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  • Contributors LJ collected and analysed the data and drafted the paper. LP collected and analysed the data and revised the paper. ECB analysed the data and revised the paper. GR, SB, JEA, SM and NJF contributed to the conception and design of the research, data analysis and revision of the paper.

  • Funding The research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests JEA, SB, NJF and GR were part of the QUASER team which developed The Hospital Guide used in the intervention.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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