title: Talking about quality: exploring how 'quality' is conceptualized in European hospitals and healthcare systems.
abstract: BACKGROUND
  Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study.
  
  
  METHODS
  This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics).
  
  
  RESULTS
  The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided.
  
  
  CONCLUSIONS
  The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.
authors.affiliation: Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway. siri.wiig@uis.no.
authors.forename: Siri
authors.initials: S
authors.lastname: Wiig
authors.forename: Karina
authors.initials: K
authors.lastname: Aase
authors.forename: Christian
authors.initials: C
authors.lastname: von Plessen
authors.forename: Susan
authors.initials: S
authors.lastname: Burnett
authors.forename: Francisco
authors.initials: F
authors.lastname: Nunes
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Weggelaar
authors.forename: Boel
authors.initials: B
authors.lastname: Anderson-Gare
authors.forename: Johan
authors.initials: J
authors.lastname: Calltorp
authors.forename: Naomi
authors.initials: N
authors.lastname: Fulop
mesh_terms: D005060:Europe; D006282:Health Personnel / Q000523:psychology*; D006292:Health Priorities; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D016134:Organizational Policy; D061214:Patient Safety; D017060:Patient Satisfaction; D058996:Quality Improvement; D011787:Quality of Health Care