Organisational change theory and the use of indicators in general practice

The evidence suggesting that quality problems are caused in part by system failures ^{1, 2} has led to an emerging focus on organisational aspects necessary for improving the quality of health care. ^{3- 5} Performance measurement to raise awareness of existing practice is an important driver of improvement and indicators are one of the tools that have been developed for this purpose. Indicators have been defined as measurement tools "used to monitor and evaluate the quality of important governance, management, clinical and support functions". ⁶ Their use is increasingly viewed as an important element of quality improvement programmes in the primary care systems of many countries. ^{7, 8}

A review of the international literature ⁹ has shown that methods to improve organisational aspects generally involve four steps:

definition of performance criteria;

development of indicators and methods of assessment;

practice visits to collect data against indicators;

feedback to the practice.

Generally, the design of indicators seems to focus on practical issues while theoretical issues and underlying assumptions are seldom made clear.

Van den Hombergh ^{9, 10} was one of the first to develop a valid reliable indicator set with which to assess practice organisation known as the "visit in practice" (VIP) method. This method involves assessment using indicators covering premises and equipment, service and organisation, record keeping, delegation and collaboration, and quality improvement activities. Van den Hombergh's work assumes that a general practice is a system consisting of a number of variables that can be measured by indicators. If he had assumed that general practices were complex organisations, constantly evolving in unpredictable ways, his approach to improving the organisational quality in general practice might have been quite different.

Indicators are more than technical entities: their use to stimulate improvement also relates to concepts and ideas about organisational change. ¹¹ Examining theories is important in order to consider:

which aspects of organisation are important to measure;

how interventions can be best deployed; and

how to evaluate predictions about the use of indicators.

This paper analyses the literature on organisational change relevant to indicators and documents the practical contribution that can be made to indicators used to improve organisational quality in general practice.

ORGANISATIONAL THEORIES: THE BIG FOUR

Four theories have been applied to organisational change in...