The role of professional logics in quality register use: a realist evaluation.

BACKGROUND: Clinical practice improvements based on quality-register data are influenced by multiple factors. Although there is agreement that information from quality registers is valuable for quality improvement, practical ways of organising register use have been notoriously difficult to realise. The present study sought to investigate the mechanisms that lead various clinicians to use quality registers for improvement. METHODS: This research involves studying individuals' decisions in response to a Swedish programme focusing on increasing the use of quality registers. Through a case study, we focused on heart failure care and its corresponding register: the Swedish Heart Failure Register. The empirical data consisted of a purposive sample collected longitudinally by qualitative methods between 2013 and 2015. In total, 18 semi-structured interviews were carried out. We used realist evaluation to identify contexts, mechanisms, and outcomes. RESULTS: We identified four contexts - registration, use of output data, governance, and improvement projects - that provide conditions for the initiation of specific mechanisms. Given a professional theoretical perspective, we further showed that mechanisms are based on the logics of either organisational improvement or clinical practice. The two logics offer insights into the ways in which clinicians choose to embrace or reject certain registers' initiatives. CONCLUSIONS: We identified a strong path dependence, as registers have historically been tightly linked to the medical profession's competence. Few new initiatives in the studied programme reach the clinical context. We explain this through the lack of an organisational improvement logic and its corresponding mechanisms in the context of the medical profession. Implementation programmes must understand the logic of clinical practice; that is, be integrated with the ways in which work is carried out in everyday practice. Programmes need to be better at helping core health professionals to reach the highest standards of patient care.

One lens missing? Clarifying the clinical microsystem framework with learning theories.

INTRODUCTION: The clinical microsystem (CMS) approach is widely used and is perceived as helpful in practice but, we ask the question: "Is its learning potential sufficiently utilized?" OBJECTIVES: To scrutinize aspects of learning within the CMS framework and to clarify the learning aspects the framework includes and thereby support the framework with the enhanced learning perspective that becomes visible. METHODS: Literature on the CMS framework was systematically searched and selected using inclusion criteria. An analytical tool was constructed in the form of a theoretical lens that was used to clarify learning aspects that are associated with the framework. FINDINGS: The analysis revealed 3 learning aspects: (1) The CMS framework describes individual and social learning but not how to adapt learning strategies for purposes of change. (2) The metaphorical language of how to reach a holistic health care system for each patient has developed over time but can still be improved by naming social interactions to transcend organizational boundaries. (3) Power structures are recognized but not as a characteristic that restricts learning due to asymmetric communication. CONCLUSION: The "lens" perspective reveals new meanings to learning that enhance our understanding of health care as a social system and provides new practical learning strategies.