Quality Management and Managerialism in Healthcare:: A Critical Historical Survey

Quality Management and Managerialism in Healthcare creates a comprehensive and systematic international survey of various perspectives on healthcare quality management together with some of their most pertinent critiques. Chapter one starts with a general discussion of the factors that drove the introduction of management paradigms into public sector and health management contexts in the mid to late 1980s. Chapter two explores the rise of risk awareness in medicine; which, prior to the 1980s, stood largely in isolation to the implementation of managerial performance targets. Chapter three investigates the widespread adoption of performance management and clinical governance frameworks during the 1980s and 1990s. This is followed by Chapters four and five which examine systems based models of patient safety and the evidence-based medicine movement as exemplars of managerial perspectives on healthcare quality. Chapter six discusses potential future avenues for the development of alternative perspectives on quality of care which emphasise workforce involvement. The book concludes by reviewing the factors which have underpinned the managerialist trajectory of healthcare management over the past decades and explores the potential impact of nascent technologies such as 'connected health' and 'telehealth' on future developments.

The contribution of qualitative research in designing a complex intervention for secondary prevention of coronary heart disease in two different healthcare systems

Background: Developing complex interventions for testing in randomised controlled trials is of increasing importance in healthcare planning. There is a need for careful design of interventions for secondary prevention of coronary heart disease (CHD). It has been suggested that integrating qualitative research in the development of a complex intervention may contribute to optimising its design but there is limited evidence of this in practice. This study aims to examine the contribution of qualitative research in developing a complex intervention to improve the provision and uptake of secondary prevention of CHD within primary care in two different healthcare systems.

Methods: In four general practices, one rural and one urban, in Northern Ireland and the Republic of Ireland, patients with CHD were purposively selected. Four focus groups with patients (N = 23) and four with staff (N = 29) informed the development of the intervention by exploring how it could be tailored and integrated with current secondary prevention activities for CHD in the two healthcare settings. Following an exploratory trial the acceptability and feasibility of the intervention were discussed in four focus groups (17 patients) and 10 interviews (staff). The data were analysed using thematic analysis.

Results: Integrating qualitative research into the development of the intervention provided depth of information about the varying impact, between the two healthcare systems, of different funding and administrative arrangements, on their provision of secondary prevention and identified similar barriers of time constraints, training needs and poor patient motivation. The findings also highlighted the importance to patients of stress management, the need for which had been underestimated by the researchers. The qualitative evaluation provided depth of detail not found in evaluation questionnaires. It highlighted how the intervention needed to be more practical by minimising administration, integrating role plays into behaviour change training, providing more practical information about stress management and removing self-monitoring of lifestyle change.

Conclusion: Qualitative research is integral to developing the design detail of a complex intervention and tailoring its components to address individuals' needs in different healthcare systems. The findings highlight how qualitative research may be a valuable component of the preparation for complex interventions and their evaluation.