In surgical department C an enhanced recovery program for patients having undergone liverresections was started. The aims of enhanced recovery are to make the patient able to receive adjuvant therapy and/or resume daily activities. Over the last decade the Danish Healthcare system has been constantly criticized for being closed and nontransparent. In the gradual evolution from medical fixation to being patient centered demands arose not only in terms of legislation, but also medical training and quality development to meet this new era. The Danish accreditation Model was inspired by the previous work in Institute for Health Care Improvement and Deming´s cycle served inspiration for quality improvement. This was done in order to reestablish the legitimacy of the Health authorities. It was implemented in 2005 and consisted of Standards, Evaluation and Reporting. Standards were patient pathway, disease specific and organizational. The evaluation processes were internal and external. Reporting consisted of feed-back, accreditation and publication. Every year since 2000 a nationwide survey of patient satisfaction (LUP) has been published to describe patient experiences in connection with the patient pathway. In the introduction to this publication the Danish Minister of Internal Affairs and Health together with the political leader of the Danish Regions stated, that the satisfaction of admitted patients was 93 %, and that there were several areas in which the quality could be improved. Quality is difficult to evaluate for medical services and was defined as “the properties of a service or a product, which is related to its ability to fulfill specified or general needs and expectations”. This is related to different dimensions, aspects and perspectives. Satisfaction was defined as ”the sensation built on experience and expectations”. LUP is part of the reward structure through its publication and indirectly affects the budgets of the departments because it supports the free choice of the patients, which is part of the New Public Management philosophy of letting the money follow the patients. The purpose of this thesis was to determine the most essential barriers to good governance in the Danish Health Care system. Where good governance was defined as governance aligned with reward structure and measurement of performance to support the general strategy. The barriers are that the reward system and performance measurement do not support good governance, because they do not support the right behavior to increase performance, do not motivate, are institutionalized. LUP was sent out to 140.000 patients, who had been admitted more than 24 hours to a department. We wanted to check if the patients were equally satisfied with our enhanced recovery program, and therefore we sent out a reduced LUP questionnaire to a selected group of patients, where we could use the previous LUP as a historical control and found no difference. In this process it became apparent, that there were several methodological problems in LUP, why we made our own questionnaire to address these. The problems were methodological and related both to the phrasing and the reporting. We then sent our newly developed questionnaire to a matching group of patients in which we made a paired analysis of attitudes and experience, which made us able to define causal relations, which was the purpose of the LUP, but which could not be done due its composition. The fact that LUP is used as direction for action renders it an enormous impact on health care professionals´ motivation. Because the contract is not clear, a manipulation takes place, and cream-skimming is favored by the survey, because it only examines one perspective of quality, which is patient perceived quality, whereas the rest of the criteria, concerning pathway are related to organization and structure which is attributable to the principal, and therefore is not controllable for the professionals. It is part of the accreditation process, which is regulative, and does not make professional sense in the way it is implemented, due to an excess registration, that is not evidence based. Quality has become an institutional myth and isomorphism is prevailing due to the institutionalization of the quality improvement organization. This fact is further underlined by the lack of an efficient electronic patient paper to support registration and research. In a political environment with a lot of double communication like “remove all bureaucracy, but register everything, save but it must not affect quality”, it is increasingly hard for the line leader to motivate the healthcare professionals, also due to the fact that the registration is beyond meaningfulness, and their primary motivation factors professional pride, social recognition, and autonomy are not respected through the publication of surveys and they are further subdued to control by the accreditation structure that does not make professional sense, because it is only a benchmark of perceived quality to be used politically and not a reliable instrument for quality improvement or related to treatment specific indicators.
|Uddannelser||Master of Public Governance , (Masteruddannelse) Afsluttende afhandling|