Sustaining new work practices in long-term care

Abstract In healthcare, more and more quality improvement collaboratives (QIC’s) have been started to improve the quality of care. In these QIC’s, several teams from different organizations work together by means of the break-through method, in order to improve specific parts of their care processes. While many studies have examined the effectiveness of QIC’s, by studying the results of implementation efforts in the short term, less research has been conducted to determine what happens beyond that point. The aim of this study is to investigate the influence of the inner organizational context on the sustainability of new work practices in long-term care. Sustainability can be distinguished by two dimensions: routinization and institutionalization. Routinization is the process in which actors within the organization develop and adapt their routines to new work practices. Institutionalization is the process in which the organization adapts and develops its facilities in order to make routinization possible. The level of sustainability can, among others, be affected by the inner organizational context. This context entails the following aspects: organizational support, organizational culture, leadership, and a commitment to quality improvement. These aspects have been shown to affect the implementation of new work practices. Less knowledge is available about their influence on sustainability. From 2006 to 2009, a large-scale improvement project called "Care for Better" was run in the Netherlands. Its objective was to improve the quality of care for the elderly, the disabled and home care. The program consisted of seven QIC’s, each focusing on a specific quality topic: pressure ulcers, eating and drinking, prevention of sexual abuse, client autonomy, medication safety, fall prevention, and prevention of (social) behavioral problems. This study analyzes secondary data from a larger evaluation study of 217 QI teams participating in the “Care for Better” program. Data on these QI teams was collected by the Institute of Health Policy and Management (iBMG) of the Erasmus University Rotterdam at two points in time: a week after the final meeting was held at the end of the collaboration (T1), and twelve months later at the follow-up measurement (T2). The individuals who had completed both the T1 and T2 questionnaires were included in this study (N= 69; 23% response rate). Correlations were calculated to analyze the relationship between the factors of the inner organizational context and sustainability. Subsequently, the variables with a significant effect on the dependent variables were included in multivariate regression analyses. The results show that leadership has a significant influence on both routinization and institutionalization (β= 0.55 p= 0.00 and β= 0.58 p= 0.00). Also, the frontline professionals had a significantly lower level of perceived institutionalization than management and quality staff. Furthermore, the results show that the improvement team project leaders scored significantly more positive on routinization than the other team members. All other variables showed no significant relationship with either routinization or institutionalization. This research shows that there is a clear difference between the success factors in the implementation phase in contrast with the sustainability phase. This indicates that organizations need to continue to devote attention to the new work practices after the implementation phase has ended in order to sustain them. The awareness of the importance of the sustainability phase is essential for an organization, otherwise the investment made in the implementation phase is lost. These findings are specifically interesting for managers. Even without a budget, team leaders can influence the level of sustainability. The findings align with other studies about the relationship between leadership and sustainability. The second finding of the study is that managers experience a different level of sustainability than frontline professionals. For example, managers can have the perception that they have facilitated and supported their employees in order to sustain the new work practices, while frontline professionals may have a different opinion about the sufficiency of these facilities and support. For managers, it is relevant to discuss this topic during the sustainability phase in order to reduce this “gap” in the perceived sustainability of the new work practices. To conclude, this research found evidence that success factors of the inner organizational context in the implementation phase and the sustainability phase differ from each other.