Hostname: page-component-cd9895bd7-mkpzs Total loading time: 0 Render date: 2024-12-25T03:37:24.011Z Has data issue: false hasContentIssue false

Understanding institutional conversion: the case of the National Reporting and Learning System

Published online by Cambridge University Press:  15 June 2012

Anneliese Dodds*
Affiliation:
Department of Sociology and Public Policy, Aston University, Birmingham, UK
Naonori Kodate*
Affiliation:
School of Applied Social Science, University College Dublin, Ireland
*
Anneliese DoddsLecturer Department of Sociology and Public Policy Aston University Aston Triangle Birmingham B4 7ET UK Tel.: +44 (0)121 204 3067 Fax: +44 (0)121 204 3696 Email: [email protected]
Naonori KodateLecturer School of Applied Social Science University College Dublin Belfield, Dublin 4 Republic of Ireland Tel.: +353 (0)1 716 8472 Fax: +353 (0)1 716 1197 Email: [email protected]

Abstract

This article focuses on one type of institutional change: conversion. One innovative approach to institutional change, the “political-coalitional approach”, acknowledges that: institutions can have unintended effects, which may privilege certain groups over others; institutions are often created and sustained through compromise with external actors; and institutions’ external context can vary significantly over time, as different coalitions’ power waxes and wanes. This approach helps explain the conversion of one institution drawn from the UK National Health Service, the National Reporting and Learning System. However, the shift of this system from producing formative information to facilitate learning to promote safer care, towards producing summative information to support resource allocation decisions, cannot be explained merely by examining the actions of external power coalitions. An internal focus, which considers factors that are normally viewed as “organisational” (such as leadership and internal stability), is also required.

Type
Research Article
Copyright
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Alvarez-Rosete, A.Mays, N. (2008) Reconciling two conflicting tales of the English health policy process since 1997. British Politics 3(2): 183203.CrossRefGoogle Scholar
Béland, D. (2007) Ideas and institutional change in social security: conversion, layering and policy drift. Social Science Quarterly 88(1): 2038.CrossRefGoogle Scholar
British Medical Journal (2004) Correction for Katikireddi, National reporting system for medical errors is launched. British Medical Journal 328: 884.Google Scholar
Burau, V.Vrangbaek, K. (2008) Institutions and non-linear change in governance. Reforming the governance of medical performance in Europe. Journal of Health Organization and Management 22(4): 350367.CrossRefGoogle ScholarPubMed
Burns, F. (2007) Name of the game is not ‘no blame’. Health Services Journal, Jan. 1.Google Scholar
Campbell, D. (2008) Doctors are warned over drug deaths. Observer, Jul. 6.Google Scholar
Carlowe, J. (2009) How safe are patients in primary care? Nursing Times, Apr. 28.Google Scholar
Carpenter, D. P. (2010) Reputation and power: organizational image and pharmaceutical regulation at the FDA. Princeton: Princeton University Press.Google Scholar
Carpenter, D. P. (2001) The forging of bureaucratic autonomy: reputations, networks, and policy innovation in executive agencies, 1862–1928. Princeton: Princeton University Press.Google Scholar
Clews, G. (2007) Under-fire agency plans its future. Health Services Journal, Jan. 1.Google Scholar
Coombes, R. (2005) NHS errors led to more than 800 deaths. British Medical Journal 331(254).CrossRefGoogle ScholarPubMed
Craven, N.Merrick, J. (2006) Mixed hospital wards: 12 years of shame. Daily Mail, Jul. 11.Google Scholar
Creamer, R. (2008) Trusts sign up to patient safety campaign. Health Services Journal, Jun. 20.Google Scholar
Daily Mail (2005) Hospital blunders ‘kill 840 patients a year’. Daily Mail, Jul. 22.Google Scholar
Darzi, A. (2009) A time for revolutions – the role of clinicians in health care reform. New England Journal of Medicine 361(6): e8.CrossRefGoogle ScholarPubMed
Dent, E. (2009) Patient deaths due to errors up 60 per cent – Liberal Democrats. Health Services Journal, Jan. 6.Google Scholar
Department of Health (2000) An organisation with a memory. London: Department of Health.Google Scholar
Department of Health (2010) Liberating the NHS: report of the arm's-length bodies review. London: Department of Health.Google Scholar
Derthick, M. (1990) Agency under stress: the Social Security Administration in American Government. Washington, DC: Brookings Institution.Google Scholar
Fletcher, M.Huehns, T. (2009) Guidance on implementing the never events framework. Health Services Journal, May, 12.Google Scholar
Fung, A., Graham, M.Weil, D. (2007) Full disclosure. The perils and promise of transparency. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Gould, M. (2008) Patient safety records: silent witness. Health Services Journal, Sep. 15.Google ScholarPubMed
Grant, W. (2010) Policy instruments in the Common Agricultural Policy. West European Politics 33(1): 2238.CrossRefGoogle Scholar
Greenwood, L. (2003) Slip gloss. Health Services Journal, Jul. 31.Google ScholarPubMed
Greer, S.Jarman, H. (2007) The Department of Health and the civil service: from Whitehall to Department of Delivery to where? London: Nuffield Institute.Google Scholar
Greif, A.Laitin, D. (2004) A theory of endogenous institutional change. American Political Science Review 98(4): 1448.CrossRefGoogle Scholar
Hacker, J. S. (2004) Privatizing risk without privatizing the welfare state: the hidden politics of social policy retrenchment in the United States. American Political Science Review 98(2): 243260.CrossRefGoogle Scholar
Hairon, N. (2008) Guidelines focus on improving patient safety in mental health. Nursing Times, Nov. 28.Google ScholarPubMed
Hall, P. A.Taylor, R. C. R. (1996) Political science and the three new institutionalisms. Political Studies 44: 936957.CrossRefGoogle Scholar
Ham, C. (2008) Competition and integration in the English National Health Service. British Medical Journal 336: 805807.CrossRefGoogle ScholarPubMed
Harrison, M. (2004) Implementing change in health systems: market reforms in the United Kingdom, Sweden, and the Netherlands. London: Sage.Google Scholar
Hawkes, N. (2006) £30m to curb sex attacks on wards for mentally ill. The Times, Nov. 3.Google Scholar
Health Services Journal (2007) Sir Liam announces NPSA ‘refocus’. Health Services Journal, Jan. 4.Google Scholar
Health Services Journal (2006) DoH puts safety first. Health Services Journal, Dec. 15.Google Scholar
Health Services Journal (2003a) Keep in step (1 of 2). Health Services Journal, Nov. 13.Google Scholar
Health Services Journal (2003b) Keep in step (2 of 2). Health Services Journal, Nov. 13.Google Scholar
Hoffman, B., Beyer, M., Rohe, J., Genishen, J.Gerlach, F. M. (2008) ‘Every error counts’: a web-based incident reporting and learning system for general practice. Quality and Safety in Healthcare 17: 307312.CrossRefGoogle Scholar
Hood, C.Margetts, H. (2006) The tools of government in the digital age. Basingstoke: Palgrave Macmillan.Google Scholar
Ito, T. A., Larsen, J. T., Smith, N. K.Cacioppo, J. T. (1998) Negative information weighs more heavily on the brain: the negativity bias in evaluative categorizations. Journal of Personality and Social Psychology 75(4): 887900.CrossRefGoogle ScholarPubMed
Kassim, H.Le Galès, P. (2010) Exploring governance in a multi-level polity: a policy instruments approach. West European Politics 33(1): 121.CrossRefGoogle Scholar
Katikireddi, V. (2004) National reporting system for medical errors is launched. British Medical Journal 328: 481.CrossRefGoogle ScholarPubMed
Kerr, D. J.Scott, M. (2009) British lessons on health care reform. New England Journal of Medicine 361(13): e21.CrossRefGoogle ScholarPubMed
Klein, R. (2006) The new politics of the NHS: from creation to reinvention, 5th edition ed.Oxford: Radcliffe Publishing Ltd.Google Scholar
Kmietowicz, Z. (2007) Safety agency must simplify reporting of patient incidents. British Medical Journal 334: 12.Google Scholar
Kmietowicz, Z. (2006) Agency reports cases of rape on mental health wards. British Medical Journal 333: 167.Google Scholar
Legido-Quigley, H., McKee, M., Walshe, K., Suñol, R., Nolte, E.Klazinga, N. (2008) How can quality of health care be safeguarded across the European Union? British Medical Journal 336: 920923.CrossRefGoogle ScholarPubMed
Lister, S. (2009) National Patient Safety Agency finds 10,000 child safety alerts a year. The Times, Jun. 18.Google Scholar
Lister, S. (2006) National review ordered into NHS sexual assaults. The Times, Jul. 18.Google Scholar
Lodge, M.Wegrich, K. (Eds) (2012) Executive politics in times of crisis. Basingstoke: Palgrave Macmillan.CrossRefGoogle Scholar
Lyall, J. (2006) News analysis: at risk – the safety agency that failed to set the world on fire. Health Services Journal, Sep. 28.Google Scholar
Macrae, C. (2008) Learning from patient safety incidents: creating participative risk regulation in healthcare. Health, Risk & Society 10(1): 5367.CrossRefGoogle Scholar
Mahoney, J. (2000) Strategies of causal inference in small-N analysis. Sociological Methods and Research 28(4): 387424.CrossRefGoogle Scholar
Mahoney, J.Thelen, K. (2009) Explaining institutional change. New York: Cambridge University Press.CrossRefGoogle Scholar
Mahoney, J.Thelen, K. (2010) A theory of gradual institutional change. In Explaining Institutional Change: Ambiguity, Agency, and Power, Mahoney J. and Thelen K. (Ed). Cambridge: Cambridge University Press, 137.Google Scholar
Maor, M. (2010) Organisational reputation and jurisdictional claims: the case of the US Food and Drug Administration. Governance 23(1): 133160.CrossRefGoogle Scholar
March, J. G.Olsen, J. P. (1989) Rediscovering institutions: the organizational basis of politics. New York: The Free Press.Google Scholar
Merton, R. K. (1936) The unanticipated consequences of purposive social action. American Sociological Review 1(6): 894904.CrossRefGoogle Scholar
Moran, M. (1999) Governing the health care state: a comparative study of the United Kingdom, the United States, and Germany. Manchester: Manchester University Press.Google Scholar
National Patient Safety Agency (2010) Cached website. Retrieved using Google search engine, accessed 10 September 2010.Google Scholar
National Patient Safety Agency (2008) Rapid Response Report: NPSA/2008/RRR010: From Reporting to Learning. London: NPSA.Google Scholar
North, D. C. (1998) Five propositions about institutional change. In Explaining social institutions. Jack Knight and Itai Sened (Eds). Michigan: Michigan University Press.Google Scholar
North, D. C. (1990) Institutions, institutional change and economic performance. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Nursing Times (2009) Patient safety incidents rise 12% in six month. Oct. 8.Google Scholar
Oakeshott, I. (2006) 200 epidural blunders admitted after three women die. Sunday Times, Jun. 18.Google Scholar
Orren, K.Skowronek, S. (2004) The search for American political development. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Osborn, S.Williams, S. (2003) The journey to safety. Health Services Journal, Nov. 13.Google ScholarPubMed
Osborn, S.Williams, S. (2006) Letter in regards to Health and Safety Records. British Journal of Nursing 15(4): 211.Google Scholar
Parker, J. (2004) Resourcing clinicians for the patient safety culture. Practice Nursing 15(2): 91.CrossRefGoogle Scholar
Pham, J. C., Colantuoni, E., Dominici, F., Shore, A., Macrae, C., Scobie, S., Fletcher, M., Cleary, K., Goeschel, C. A.Pronovost, P. J. (2010) The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. Quality and Safety in Health Care e-published before print.Google Scholar
Pierson, P. (2004) Politics in time: history, institutions, and social analysis. Princeton, New Jersey: Princeton University Press.CrossRefGoogle Scholar
Pierson, P. (2000) Increasing returns, path dependence, and the study of politics. American Political Science Review 94(2): 251267.CrossRefGoogle Scholar
Pollitt, C., Bathgate, K., Caulfield, J., Smullen, A.Talbot, C. (2001) Agency fever? Analysis of an international policy fashion. Comparative Policy Analysis 3(3): 271290.Google Scholar
Porter, T. (1995) Trust in numbers: the pursuit of objectivity in science and public life. Princeton, NJ: Princeton University Press.Google Scholar
Power, M. (2004) Counting, control and calculation: reflections on measuring and management. HumanRelations 57(6): 765783.Google Scholar
Public Accounts Committee (2006) Fifty-first Report of Session 2005–06, A safer place for patients: learning to improve patient safety. HC 831, London: Her Majesty's Stationery Office.Google Scholar
Reason, J. (1998) Achieving a safe culture: theory and practice. Work and Stress 12(3): 293306.CrossRefGoogle Scholar
Runciman, W. B., Sellen, A., Webb, R. K., Williamson, J. A., Currie, M., Morgan, C.Russell, W. J. (1993) Errors, incidents and accidents in anesthetic practice. Anaesthesia and Intensive Care 21(5): 506519.CrossRefGoogle Scholar
Sari, A. B. A., Sheldon, T. A., Cracknell, A.Turnbull, A. (2007) Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. British Medical Journal 334(79).CrossRefGoogle Scholar
Scally, G.Donaldson, L. J. (1998) Looking forward: clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal 317(7150): 6165.CrossRefGoogle Scholar
Skowronek, S. (1982) Building a new American state: the expansion of national administrative capacities, 1877–1920. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Smith, A. F.Mahajan, R. P. (2009) National critical incident reporting: improving patient safety. British Journal of Anaesthesia 103(5): 623625.CrossRefGoogle ScholarPubMed
Smith, R. (2010) Quango cut could cost lives: charity. The Telegraph, Jul. 26.Google Scholar
Soroka, S. N. (2006) Good news and bad news: asymmetric responses to economic information. Journal of Politics 68: 372385.CrossRefGoogle Scholar
Steinmo, S., Thelen, K.Longstreth, F. (Eds) (1992) Structuring politics. Historical institutionalism in comparative analysis. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Storey, J. (2011) Steering whilst rowing: governing and managing health services from the centre. Journal of Health Organization and Management 25(6): 625644.CrossRefGoogle ScholarPubMed
Streeck, W.Thelen, K. (Eds) (2005) Beyond continuity: institutional change in advanced political economies. Oxford: Oxford University Press.Google Scholar
Teles, S. M. (2008) The rise of the Conservative legal movement: the battle for control of the law. Princeton: Princeton University Press.CrossRefGoogle Scholar
Thelen, K. (2009) Institutional change in advanced political economies. British Journal of Industrial Relations 47(3): 471498.CrossRefGoogle Scholar
Thelen, K. (2004) How institutions evolve: the political economy of skills in Germany, Britain, the United States, and Japan. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
The Times (2006) Publish and reform: sexual abuse in mental health units is the NHS's dirty secret. Editorial. The Times, Jul. 10.Google Scholar
Ting, M. M. (2002) A theory of jurisdictional assignments in bureaucracies. American Journal of Political Science 46(2): 364378.CrossRefGoogle Scholar
Tuohy, C. J. (1999) Accidental logics: the dynamics of change in the health care arena in the United States, Britain, and Canada. Oxford: Oxford University Press.CrossRefGoogle Scholar
Vincent, C., Aylin, P., Franklin, B. D., Holmes, A., Iskander, S., Jacklin, A.Moorthy, K. (2008) Is health care getting safer? British Medical Journal 337: a2426.CrossRefGoogle ScholarPubMed
Walshe, K. (2003) Regulating healthcare: a prescription for improvement?. Milton Keynes: Open University Press.Google Scholar
White, C. (2007) Safety agency wants to do more to engage clinicians, its head says. British Medical Journal 335: 847.CrossRefGoogle Scholar
Woll, C.Jacquot, S. (2010) Using Europe: strategic action in multi-level politics. Comparative European Politics 8(1): 110142.CrossRefGoogle Scholar
Woodward, S. (2009) The inseparable link between nursing and patient safety. Nursing Times, Mar. 31.Google ScholarPubMed
World Health Organization (2005) WHO draft guidelines for adverse event reporting and learning system: from information to action. Geneva, Switzerland: WHO.Google Scholar
Wright, J. S. F. (2009) The regulatory state and the UK Labour Government's re-regulation of provision in the English National Health Service. Regulation and Governance 3: 334359.CrossRefGoogle Scholar