International Journal of Integrated Care, 15 April 2009 - ISSN 1568-4156
Book review
Organizing for quality: the improvement journeys of leading hospitals in Europe and the United States
Paul Bates, Peter Mendel, Glenn Robert
Abingdon: Radcliffe Publishing Ltd, 2008, pp 252,
ISBN 978 184619 151 0
Simon Neby, Researcher, Stein Rokkan Center for Social Studies, N-5015 Bergen, Norway

The empirical theme for this book is quality improvement (QI), whereas the more theoretical aspects concern a range of issues common to organization theory. The book essentially provides a collection of seven case studies of successful QI adventures. It is through focusing on the complex organizational contexts of QI that the book contributes to those interested in integrated care; a main theme is in fact the integration of QI into the organizational settings of healthcare providers in Europe and the US.

The chapters are structured around their purposes: on the one hand, Chapters 2 through 8—the book’s main body—are in-depth presentations of studies of renowned service providers having undertaken QI efforts. These chapters are very rich with detail and span a large selection of organizational themes, whether the themes in question are the mindfulness sense-making taking place at San Diego Children’s Hospital; the importance of identity to organizational learning in the Royal Devon and Exeter NHS Foundation Trust; or the relevance of social mobilization to the achievements of the AIDS treatment at the Albany Medical Center. The seven case studies are in principle told as stories of quests for increased quality, underlining certain themes particularly important to each case. On the other hand, the book does not simply report research findings: Chapter 1 provides an intriguing point of departure making a series of bold statements about the authors’ purposes and analytical designs. Chapter 9 gives practical advice, even providing a recipe-like codebook for QI. Chapter 10 provides customized points of view for researchers less preoccupied with engaging in actual improvement than in researching and understanding it. Chapter 11 is an epilogue pointing to lessons learned for those attempting both similar studies and resembling QI work. These four chapters contribute to expecting more from this book than others—this book is ambitious in its attempt to reach audiences within communities of both practice and research.

In terms of the book’s design, the authors state five common analytical mistakes that they explicitly seek to remedy. In short, the aims are to conduct ‘deep dives’ rather than cruising the surface of QI; to move beyond the ‘what’ and into the ‘how and why’; to further process orientation over variable oriented analyses; to combine macro and micro approaches; and, lastly, to provide an organizational/sociological perspective on quality improvement instead of describing the “science of QI”. The selection of cases suggests a belief that success stories are better suited for learning (regardless of audience) than stories of failure; this leaves the impression that the authors aim to provide inspiration.

I remain sympathetic to the very explicit approaches taken in the case studies presented. The detail and multiplicity of themes that run through these chapters yields ample insight into the world of QI, although the focus on positive accomplishments and the relative absence of failure stories sometimes seem to stress fair-weather pictures over realistic forecasts. Generalization is explicitly oriented around six themes accompanied by challenges at the organizational level; structural, political, cultural, educational, emotional, and the physical and technological challenges are identified as common ground between the seven case studies. This opens for a perspective containing several levels and dimensions, stressing complexity.

There are a few issues concerning the explicitly stated aims of Chapter 1, however, as the authors themselves propose an organizational perspective. Consider the macro/micro discussion and the case studies’ relevance for healthcare providers in other countries or different systems: the micro distinctions are easily definable, but what are the boundaries of the macro frames of reference? The detailed case studies leave something to be desired in terms of systems level approaches and the role of politics for QI. Moreover, there is the contradiction between, firstly, in Chapter 9 proposing something of a cookbook for QI efforts, and, secondly, in Chapter 11 stating that “…there was no single best way to achieve excellence” (p. 205). Although unavoidable due to the ambitions of the project, this contradiction leaves the role played by organizational theory as a basis for normative and instrumental approach unresolved.

In sum, this is a book that undoubtedly will remain controversial to a number of researchers (in particular organization researchers) because of its case-based, evidence-oriented (yet ambiguous) combination of research and advice. The ambitious statements made by the authors in the early pages spurs considerable curiosity, however, and if asked whether the book is worth reading, whether by researchers or medical officers, I would not hesitate to say yes.