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Cited by 603Health Policy Implementation ScienceEvaluation and Performance AssessmentHealthcare Quality and Management

Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program

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DIXON-WOODS, MARY, BOSK, CHARLES L., AVELING, EMMA LOUISE, GOESCHEL, CHRISTINE A., PRONOVOST, PETER J.·2011·Milbank Quarterly
DOI 10.1111/j.1468-0009.2011.00625.xPMC PMC3142336
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Abstract

CONTEXT: Understanding how and why programs work-not simply whether they work-is crucial. Good theory is indispensable to advancing the science of improvement. We argue for the usefulness of ex post theorization of programs. METHODS: We propose an approach, located within the broad family of theory-oriented methods, for developing ex post theories of interventional programs. We use this approach to develop an ex post theory of the Michigan Intensive Care Unit (ICU) project, which attracted international attention by successfully reducing rates of central venous catheter bloodstream infections (CVC-BSIs). The procedure used to develop the ex post theory was (1) identify program leaders' initial theory of change and learning from running the program; (2) enhance this with new information in the form of theoretical contributions from social scientists; (3) synthesize prior and new information to produce an updated theory. FINDINGS: The Michigan project achieved its effects by (1) generating isomorphic pressures for ICUs to join the program and conform to its requirements; (2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; (3) reframing CVC-BSIs as a social problem and addressing it through a professional movement combining "grassroots" features with a vertically integrating program structure; (4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; (5) harnessing data on infection rates as a disciplinary force; and (6) using "hard edges." CONCLUSIONS: Updating program theory in the light of experience from program implementation is essential to improving programs' generalizability and transferability, although it is not a substitute for concurrent evaluative fieldwork. Future iterations of programs based on the Michigan project, and improvement science more generally, may benefit from the updated theory present here.

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  • There have been calls for more explicit use of theory to identify influences on behaviour change, understand mechanisms of change, and inform implementation interventions.

    “There have been calls for more explicit use of theory to identify influences on behaviour change (i.e.facilitators of and barriers to change) [1,2]; understand mechanisms of change, including how and in which contexts interventions are effective [3][4][5]; and inform implementation interventions [6][7][8][9][10][11][12][13].”

    From A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems (2017) · cites this paper as [3]

  • Data collected for the evaluation included routinely collected data, custom-designed surveys and qualitative data.

    “Data collected for the evaluation included routinely collected data [33, 44], custom-designed surveys [13, 16, 32, 72, 76, 79] and qualitative data.”

    From Using theory of change to design and evaluate public health interventions: a systematic review (2015) · cites this paper as [44]

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Research works printed but not linked: 75

  1. Adler, P.S., S.W. Kwon, and C. Heckscher. 2008. Professional Work: The Emergence of Collaborative Community. Organization Science 19(2):359-76.
  2. Ariely, D., and M.I. Norton. 2009. Conceptual Consumption. Annual Review of Psychology 60:475-99.
  3. Aveling, E.L. 2010. The Impact of Aid Chains: Relations of Depen- dence or Supportive Partnerships for Community-Led Interven- tions? AIDS Care 22(1):1588-97.
  4. Bate, S.P. 1994. Strategies for Cultural Change. Oxford: Butterworth- Heinneman.
  5. Bate, S.P. 2000. Changing the Culture of a Hospital: From Hierarchy to Networked Community. Public Administration 78(3):485-512.
  6. Bate, S.P., and G. Robert. 2002. Knowledge Management and Commu- nities of Practice in the Private Sector: Lessons for Modernising the National Health Service in England and Wales. Public Administration 80(4):643-63.
  7. Bate, S.P., G. Robert, and H. Bevan. 2004. The Next Phase of Healthcare Improvement: What Can We Learn from Social Movements? Quality & Safety in Health Care 13(1):62-66.
  8. Benford, R.D., and D.A. Snow. 2000. Framing Processes and Social Movements: An Overview and Assessment. Annual Review of Sociology 26(1):611-39.
  9. Bevan, G., and C. Hood. 2006. What's Measured Is What Matters: Targets and Gaming in the English Public Health Care System. Public Administration 84(3):517-38.
  10. Birckmayer, J.D., and C. Weiss. 2000. Theory-Based Evaluation in Practice: What Do We Learn? Evaluation Review 24(4):407-31.
  11. Black, N., and E. Thompson. 1993. Obstacles to Medical Audit: British Doctors Speak Out. Social Science & Medicine 36(7):849-56.
  12. Bosk, C.L. 2003. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press.
  13. Bosk, C.L., M. Dixon-Woods, C.A. Goeschel, and P.J. Pronovost. 2009. The Art of Medicine: Reality Check for Checklists. The Lancet 374(9688):444-45.
  14. Bovens, M. 1999. The Quest for Responsibility-Accountability and Citizenship in Complex Organizations. Organizational Studies 20(4):706-7.
  15. Braithwaite, J. 2008. The Regulatory State? In The Oxford Handbook of Political Institutions, ed. R. Rhodes, S. Binder, and B.A. Rockman, 407-30. Oxford: Oxford University Press.
  16. Buchanan, D., R. Addicott, L. Fitzgerald, E. Ferlie, and J.I. Baeza. 2007. Nobody in Charge: Distributed Change Agency in Healthcare. Hu- man Relations 60(7):1065-90.
  17. Bucher, R. 1962. Pathology: A Study of Social Movements within a Profession. Social Problems 10(1):40-51.
  18. Campbell, C., and C. MacPhail. 2002. Peer Education, Gender and the Development of Critical Consciousness: Participatory HIV Pre- vention by South African Youth. Social Science & Medicine 55(2): 331-45.
  19. Chen, H.T., and P.H. Rossi. 1983. Evaluating with Sense: The Theory- Driven Approach. Evaluation Review 7(3):283-302.
  20. Connerton, P. 1989. How Societies Remember. Cambridge: Cambridge Uni- versity Press.
  21. Cornish, F. 2006. Empowerment to Participate: A Case Study of Par- ticipation by Indian Sex Workers in HIV Prevention. Journal of Community and Applied Social Psychology 16(4):301-15.
  22. Cornish, F., and R. Ghosh. 2007. Necessary Contradictions of "Community-Led" Health Promotion: A Case Study of HIV Pre- vention in an Indian Red Light District. Social Science & Medicine 64(2):496-507.
  23. Davidoff, F. 2009. Heterogeneity Is Not Always Noise. JAMA 302(23):2580-86.
  24. Davies, H., A. Powell, and R. Rushmer. 2007. Why Don't Clinicians Engage with Quality Improvement? Journal of Health Services Research & Policy 12(3):129-30.
  25. DiMaggio, P.J., and W.W. Powell. 1983. The Iron Cage Revisited: Insti- tutional Isomorphism and Collective Rationality in Organizational Fields. American Sociological Review 48(2):147-60.
  26. Dixon-Woods, M. 2010. Why Is Patient Safety So Hard? A Selective Review of Ethnographic Studies. Journal of Health Services Research & Policy 15(suppl. 1):11-16.
  27. Dixon-Woods, M., A. Suokas, E. Pitchforth, and C. Tarrant. 2009. An Ethnographic Study of Classifying and Accounting for Risk at the Sharp End of Medical Wards. Social Science & Medicine 69(3): 362-69.
  28. Dopson, S., L. Locock, E. Ferlie, and L. Fitzgerald. 2003. Evidence- Based Medicine and the Implementation Gap. Health: An Interdisci- plinary Journal for the Social Study of Health, Illness and Medicine 7(3): 311-30.
  29. Dunn, J.L. 2005. "Victims" and "Survivors": Emerging Vocabularies of Motive for "Battered Women Who Stay." Sociological Inquiry 75(1):1-30.
  30. Ericson, R.V. 1995. The News Media and Accountability in Crim- inal Justice. In Accountability for Criminal Justice: Selected Es- says, ed. P.C. Stenning,135-61. Toronto: University of Toronto Press.
  31. Feynman, R.P. 1999. Cargo Cult Science: Some Remarks on Science, Pseudoscience, and Learning How to Not Fool Yourself. In The Pleasure of Finding Things Out, by R.P. Feynman and J. Robbins, 205-16. Cambridge, MA: Perseus Books.
  32. Finn, R. 2008. The Language of Teamwork: Reproducing Professional Divisions in the Operating Theatre. Human Relations 61(1):103- 130.
  33. Finn, R., G. Currie, and G. Martin. 2010. Team Work in Context: Insti- tutional Mediation in the Public-Service Professional Bureaucracy. Organization Studies 31(8):1069-97.
  34. Freidson, E. 1988. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago: University of Chicago Press.
  35. Gastmeier, P., and C. Geffers. 2006. Prevention of Catheter-Related Bloodstream Infections: Analysis of Studies Published between 2002 and 2005. Journal of Hospital Infection 64(4):326-35.
  36. Gillespie, A., F. Cornish, E.L. Aveling, and T. Zittoun. 2008. Conflict- ing Community Commitments: A Dialogical Analysis of a British Woman's World War II Diaries. Journal of Community Psychology 36(1):35-52.
  37. Guareschi, P.A., and S. Jovchelovitch. 2004. Participation, Health and the Development of Community Resources in Southern Brazil. Jour- nal of Health Psychology 9(2):311-22.
  38. Halbwachs, M., and L.A. Coser. 1992. On Collective Memory. Chicago: University of Chicago Press.
  39. Hilgartner, S., and C.L. Bosk. 1988. The Rise and Fall of Social Prob- lems: A Public Arenas Model. American Journal of Sociology 94(1):53.
  40. Hughes, E.C. 1958. Men and Their Work. Glencoe, IL: Free Press.
  41. Innes, J.E., and D.E. Booher. 1999. Consensus Building as Role Playing and Bricolage toward a Theory of Collaborative Planning. Journal of the American Planning Association 65(1):9-26.
  42. Katz, J. 1977. Cover-up and Collective Integrity: On the Natural Antag- onisms of Authority Internal and External to Organizations. Social Problems 25(1):3-17.
  43. Kunda, G. 2006. Engineering Culture: Control and Commitment in a High- Tech Corporation. Philadelphia: Temple University Press.
  44. Latané, B., K. Williams, and S. Harkins. 1979. Many Hands Make Light the Work: The Causes and Consequences of Social Loafing. Journal of Personality and Social Psychology 37(6):822-32.
  45. Latour, B. 1987. Science in Action. Milton Keynes: Open University Press.
  46. Lazega, E. 2000. Rule Enforcement among Peers: A Lateral Control Regime. Organization Studies 21(1):193-214.
  47. Lomas, J. 2005. Using Research to Inform Healthcare Managers' and Policy Makers' Questions: From Summative to Interpretive Synthe- sis. Healthcare Policy 1(1):55-71.
  48. Lowndes, V., and C. Skelcher. 1998. The Dynamics of Multi- Organizational Partnerships: An Analysis of Changing Modes of Governance. Public Administration 76(2):313-33.
  49. Martin, G., G. Currie, and R. Finn. 2009a. Leadership, Service Reform and Public-Service Networks: The Case of Cancer-Genetics Pilots in the English NHS. Journal of Public Administration Research and Theory 19(4):769-94.
  50. Martin, G., G. Currie, and R. Finn. 2009b. Reconfiguring or Reproduc- ing Intra-Professional Boundaries? Specialist Expertise, Generalist Knowledge and the "Modernization" of the Medical Workforce. Social Science & Medicine 68(7):1191-98.
  51. McMillan, D.W., and D.M. Chavis. 1986. Sense of Community: A Definition and a Theory. Journal of Community Psychology 14(1):6- 23.
  52. Mermel, L.A., M. Allon, E. Bouza, D.E. Craven, P. Flynn, N.P. O'Grady, I.I. Raad, B.J. Rijnders, R.J. Sherertz, and D.K. Warren. 2009. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 49(1):1-45.
  53. Mills, C.W. 1940. Situated Actions and Vocabularies of Motive. American Sociological Review 5(6):904-13.
  54. Mills, P.D., and W.B. Weeks. 2004. Characteristics of Successful Qual- ity Improvement Teams: Lessons from Five Collaborative Projects in the VHA. Joint Commission Journal on Quality and Patient Safety 30(3):152-62.
  55. Offer, A. 1997. Between the Gift and the Market: The Economy of Regard. Economic History Review 50(3):450-76.
  56. Ostrom, E. 1990. Governing the Commons: The Evolution of Institutions for Collective Action. Cambridge: Cambridge University Press.
  57. Øvretveit, J., P. Bate, P. Cleary, S. Cretin, D. Gustafson, K. McInnes, H. McLeod, T. Molfenter, G. Robert, S. Shortell, and T. Wilson. 2002. Quality Collaboratives: Lessons from Research. Quality and Safety in Health Care 11(4):345-51.
  58. Poteete, A.R. 2010. Working Together: Collective Action, the Commons, and Multiple Methods in Practice. Princeton, NJ: Princeton University Press.
  59. Powell, W.W., and P.J. DiMaggio. 2001. The New Institutionalism in Organizational Analysis. Chicago: University of Chicago Press.
  60. Roberts, K.A., M. Dixon-Woods, R. Fitzpatrick, K.R. Abrams, and D.R. Jones. 2002. Factors Affecting Uptake of Childhood Immunisation: A Bayesian Synthesis of Qualitative and Quantitative Evidence. The Lancet 360(9345):1596-99.
  61. Rose, N., and P. Miller. 1992. Political Power beyond the State: Prob- lematics of Government. British Journal of Sociology 43(2):173- 205.
  62. Scott, W.R. 1991. Unpacking Institutional Arguments. In The New Institutionalism in Organizational Analysis, ed. W.W. Powell and P.J. DiMaggio, 164-82. Chicago: University of Chicago Press.
  63. Shojania, K.G., and J.M. Grimshaw. 2005. Evidence-Based Quality Improvement: The State of the Science. Health Affairs 24(1):138- 50.
  64. Sitkin, S.B., and N.L. Roth. 1993. Explaining the Limited Effective- ness of Legalistic "Remedies" for Trust/Distrust. Organization Science 4(3):367-92.
  65. Spiegelhalter, D.J., K.R. Abrams, and J.P. Myles. 2004. Bayesian Ap- proaches to Clinical Trials and Health-Care Evaluation. Hoboken, NJ: Wiley.
  66. Spiegelhalter, D.J., J.P. Myles, D.R. Jones, and K.R. Abrams. 2000. Bayesian Methods in Health Technology Assessment: A Review. Health Technology Assessment 4(38):1-129.
  67. Stame, N. 2004. Theory-Based Evaluation and Types of Complexity. Evaluation 10(1):58.
  68. Stelling, J., and R. Bucher. 1972. Autonomy and Monitoring on Hos- pital Wards. Sociological Quarterly 13(4):431-46.
  69. Stone Sweet, A., N. Fligstein, and W. Sandholtz. 2001. The Institu- tionalization of European Space. In The Institutionalization of Europe, ed. A. Stone Sweet, N. Fligstein, and W. Sandholtz, 1-28. Oxford: Oxford University Press.
  70. Sutton, J.R., F. Dobbin, J.W. Meyer, and W.R. Scott. 1994. The Legal- ization of the Workplace. American Journal of Sociology 99(4):944-71.
  71. Timmermans, S. 2003. The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press.
  72. Waring, J., and G. Currie. 2009. Managing Expert Knowledge: Orga- nizational Challenges and Managerial Futures for the UK Medical Profession. Organization Studies 30(7):755-78.
  73. Weiss, C. 1988. Evaluation for Decisions: Is Anybody There? Does Anybody Care? Evaluation Practice 9(1):5-19.
  74. Wilkinson, A., G. Godrey, and M. Marchington. 1997. Bouquets, Brick- bats and Blinkers: Total Quality Management and Employee In- volvement in Practice. Organization Studies 18(5):799-819.
  75. Zittoun, T. 2008. Learning through Transitions: The Role of Institu- tions. European Journal of Psychology of Education 23(2):165-81.

Cited by

Sorted by citations

Authors
DIXON-WOODS, M., BOSK, C. L., AVELING, E. L., GOESCHEL, C. A., & PRONOVOST, P. J.
Affiliations
Johns Hopkins University (US)
ORCID
PRONOVOST, PETER J.
Venue
Milbank Quarterly
Publisher
Wiley
Published
2011-06
Volume
89
Issue
2
Pages
167-205
ISSN
0887-378X (ISSN-L)
DOI
10.1111/j.1468-0009.2011.00625.x
PMC
PMC3142336
OpenAlex
W2132033829
Cited by
603
References
4
Citations by year
2026: 13 · 2025: 13 · 2024: 9 · 2023: 47 · 2022: 13 · 2021: 38 · 2020: 42 · 2019: 54 · 2018: 44 · 2017: 47 · 2016: 54 · 2015: 73 · 2014: 59 · 2013: 49 · 2012: 39
FWCI
91.41
Type
journal article
Language
en
Open access
Licence
doi.wiley.com/10.1002/tdm_license_1 (tdm, 1553 d)
Locations
  • Milbank Quarterly (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Leicester Research Archive (University of Leicester) (submittedVersion)
Funders
  • Robert Wood Johnson Foundation
  • Agency for Healthcare Research and Quality
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Decision Sciences › Management Science and Operations Research › Evaluation and Performance Assessment
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords
intensive care unit, infection control, improvement science, theory of change, isomorphic pressures, professional movement, normative pressure, organizational culture
MeSH terms
Emergency Medical Services, Emergency Service, Hospital, Humans, Interprofessional Relations, Michigan, Patient Care Team, Quality Assurance, Health Care, Program Evaluation, Program Development, Models, Organizational, Efficiency, Organizational, Total Quality Management

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