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Open Access Publications from the University of California

(Re)defining Healthcare Quality: Metrics, Protocols, and the Restructuring of Care Delivery

  • Author(s): Winslow, Rosalie
  • Advisor(s): Bliss, Catherine
  • et al.

Healthcare organizations in the United States are increasingly evaluated by systems that link quality measurement with regulatory and payment approaches. Operationalized through quality measurement, quality is affirmed as the basis for improving healthcare processes, outcomes, and health systems broadly. At the same time, electronic health record (EHR) and other information technology (IT) systems aimed to make care safer and more efficient, have become standard tools in healthcare settings. Galvanized by these technical advancements, quality metrics are considered crucial components of ensuring accountability for improved health outcomes and care equity.

This dissertation aims to understand healthcare quality measurement by investigating how systems of quality measurement are implemented in clinical spaces, particularly how they structure care delivery and define quality. This dissertation offers a qualitative study of the organizational and structural elements of quality and quality measurement. I conducted ethnographic observation (15 months) and interviews (n=31) at a 600-bed, acute-care hospital in New York City, which I call Borough Hospital. My analysis utilizes the accounts of healthcare clinicians and administrators, and their experiences navigating care delivery and quality in their hospital. Through this analysis, I investigate the variable meanings of quality, processes of measuring quality, and the conditions under which care is delivered at Borough Hospital.

Using the qualitative analytic methods of grounded theory and situational analysis, I deconstruct the ways in which quality and quality measurement are constructed as neutral and inevitable, how care delivery is increasingly protocolized to ensure quality, and the ensuing distancing of quality care away from the bedside. Meeting and complying with quality metrics require specific clinical care protocols and extensive documentation for reporting. These new requirements have changed the roles and responsibilities of frontline clinicians, shifting the organization of labor in the clinic. I argue that measurement-based, clinical protocols that rely on surveillance and abstracted documentation data increasingly standardize processes of quality care and distance care—that is, clinician labor— away from the bedside.

The findings of this dissertation suggest a tendency toward protocolization and narrowing definitions of quality, which can be extended into other hospital systems particularly in light of widespread consolidation. I argue that administrative prioritization of quality measurement, and in particular quality metrics, necessitates the protocolization of complex healthcare processes and increasingly relies on data-driven decision-making. Ultimately, I suggest quality care has been (re)defined by measurement-based, clinical protocols, which I call abstracted surveillance protocols, that increasingly standardize and constrain care delivery.

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