Table 3 Problems of proximity as central... | Emerald Publishing

Table 3

Problems of proximity as central epistemic fault line between performance measures and clinical practice: Supporting data

Problems of proximity: an epistemic faultline between performance measures and clinical practice
Category/theme	Data
Performance vs practice policymakers and improvement advisors use aggregated ‘practice-distant’ performance measures to direct clinicians’ practice. Efforts to exert control over clinical practice are resisted, and the validity of data produced through process improvement methods is contested on epistemic grounds	It might be very black and white that [a clinician] needs to change… And you can provide to them all the data and all the feedback in the world… [but] as frustrating as it is [they have] to make that decision [to change]. (participant 12, improvement advisor)
	I observed the policymakers puzzling over why ‘mental health’ had been highly prioritized as a topic of interest in the ECoP co-design workshop. They thought it was “too clinical” an issue, unrelated to access or flow. It was, however, revealed both front and back stage to be a significant, under-resourced problem for ED performance:
	Mental health was always, will always, always be a problem for [patient flow in] any ED… [but] I’ve been here 12 years and I’ve never had a [mental health] budget… (participant 16, hybrid nurse)
Efficiency vs. quality hybrid clinicians overtly prioritize qualitative understandings of improvements in quality—the ‘right’ kind of improvement—over quantifications of efficiency improvements prioritized by policymakers and improvement advisors	If I can’t see that there’s any benefit to the patient or to myself… I’m just not going to do it. And because I’m a senior person it’s very hard to make me. (participant 15, hybrid doctor)
	… [we need to be] demonstrating to [clinicians] what benefits this could potentially deliver for our patients, for our communities, as opposed to using… you know, the board up there around the key performance indicators indicates electronic dashboard. I don’t think that’s what really drives them… [it’s] patient outcomes and improving the quality and safety for their patients. (participant 13, improvement advisor)
Merging: Efficiency and quality attempts made to reframe process improvement and the role of improvement advisors in terms that more explicitly prioritize quality. Such attempts are relegated to the ‘backstage’ due to tight circumscription by policymakers of advisors’ official roles and identifications as experts in ‘pure’ (non-clinical) process improvement	… it’s difficult to engage senior clinicians in this. I don’t think it’s impossible but… they need to be exposed from all different angles… how does it benefit the patient, how does it benefit the hospital and other people who are also managing the patient… (participant 31, hybrid doctor)
	… [we need to] show more clinicians how these methods can improve quality, and their outcomes. Not just improve productivity and flow and wait times. (participant 21, improvement advisor)

Problems of proximity: an epistemic faultline between performance measures and clinical practice
Category/theme	Data
Performance vs practice policymakers and improvement advisors use aggregated ‘practice-distant’ performance measures to direct clinicians’ practice. Efforts to exert control over clinical practice are resisted, and the validity of data produced through process improvement methods is contested on epistemic grounds	It might be very black and white that [a clinician] needs to change… And you can provide to them all the data and all the feedback in the world… [but] as frustrating as it is [they have] to make that decision [to change]. (participant 12, improvement advisor)
	I observed the policymakers puzzling over why ‘mental health’ had been highly prioritized as a topic of interest in the ECoP co-design workshop. They thought it was “too clinical” an issue, unrelated to access or flow. It was, however, revealed both front and back stage to be a significant, under-resourced problem for ED performance:
	Mental health was always, will always, always be a problem for [patient flow in] any ED… [but] I’ve been here 12 years and I’ve never had a [mental health] budget… (participant 16, hybrid nurse)
Efficiency vs. quality hybrid clinicians overtly prioritize qualitative understandings of improvements in quality—the ‘right’ kind of improvement—over quantifications of efficiency improvements prioritized by policymakers and improvement advisors	If I can’t see that there’s any benefit to the patient or to myself… I’m just not going to do it. And because I’m a senior person it’s very hard to make me. (participant 15, hybrid doctor)
	… [we need to be] demonstrating to [clinicians] what benefits this could potentially deliver for our patients, for our communities, as opposed to using… you know, the board up there around the key performance indicators indicates electronic dashboard. I don’t think that’s what really drives them… [it’s] patient outcomes and improving the quality and safety for their patients. (participant 13, improvement advisor)
Merging: Efficiency and quality attempts made to reframe process improvement and the role of improvement advisors in terms that more explicitly prioritize quality. Such attempts are relegated to the ‘backstage’ due to tight circumscription by policymakers of advisors’ official roles and identifications as experts in ‘pure’ (non-clinical) process improvement	… it’s difficult to engage senior clinicians in this. I don’t think it’s impossible but… they need to be exposed from all different angles… how does it benefit the patient, how does it benefit the hospital and other people who are also managing the patient… (participant 31, hybrid doctor)
	… [we need to] show more clinicians how these methods can improve quality, and their outcomes. Not just improve productivity and flow and wait times. (participant 21, improvement advisor)

Source(s): Authors’ own work