Against all odds?
Understanding the emergence of accreditation of the Danish hospitals
DRAFT Working paper
NOT for quotation
Presented at Dansk Selskab for Statskundskabs Årsmøde October 2012
Peter Triantafillou, PhD, Professor
Department of Society and Globalisation, Roskilde University
Email: triant@ruc.dk
Abstract
Since 2009, the Danish healthcare services have been subjected to a mandatory, comprehensive
accreditation system known as the Danish Quality Model (Den Danske Kvalitetsmodel, DDKM).
The latter has been quite intensely criticized both in terms of its (questionable) medical benefits and
in terms of the substantial financial expenses implied by running such a system. In spite of this
critique, the Ministry of Health insisted on introducing the model in all public and (almost all)
private hospitals in Denmark. This paper applies a variety of theoretical frameworks to explain the
development of DDKM, the introduction of foreign accreditation systems, and the emergence of the
quality of Danish hospital services as an object of political problematization. It is concluded that
DDKM was introduced in favour of other accreditation models because the Ministry of Health
assumed it would minimize resistance from the medical profession. Accreditation was taken up by
Danish hospitals because other ways of managing quality had proven insufficient. Finally, hospital
quality management emerged as a pressing political issue because of new ways of categorizing and
computing examinations and treatments which, in turn, enabled systematic comparison of hospital
activities.
1
1 Introduction
Since August 2009, all public Danish hospitals and clinics have been subjected to accreditation in
shape of The Danish Quality Model (Den Danske Kvalitetsmodel, DDKM). 1 Most private hospitals
and clinics are included too as this is a precondition for receiving patients financed by public
money.2
From the very beginning, the very idea of introducing accreditation in Danish hospitals has been
met with widespread and sustained critique from various parts of the medical community including
the nurses. 3 As late as November 2011, around 1600 doctors and other medical staff signed an open
letter to the Director of Health in the Capital Region criticizing excessive demands for
documentation caused by poor IT-systems and in particular the two parallel accreditation systems
operating in the Region (DDKM and the US Joint Commission model of accreditation). The
criticism was endorsed by further 900 medical staff outside the Capital Region, even if they "only"
have to deal with one accreditation system (DDKM).
At the most general level, the criticism of the current form of hospital accreditation launched by
substantial, albeit far from all, parts of the medical profession revolves around two points. First,
various parts of the medical profession have hammered out over and again that there is absolutely
no scientific evidence that accreditation results in better clinical results, at least if by evidence we
understand randomized controlled experiments (EVIDENS, 2011). Second, accreditation is
criticized for wasting quite substantial resources on documentation and standardization which could
have been better spent on medical staff and equipment. On the one hand, no systematic analyses of
the costs of running accreditation have been conducted. The key reason for this lack is of course the
complicated nature of distinguishing between quality activities and other medical activities,
between accreditation and other quality activities. On the other hand, several figures have circulated
in the debate. Whether correct or not, these figures have served to fuel the critique against
accreditation. Thus, during the height of the debate over accreditation in 1999, the head of research
in the Danish Hospital Institute (DSI) claimed that the total running costs of operating accreditation
at any particular hospital lie between one per mille and one per cent of the hospital’s total costs,
probably closer to one per cent (So ein ding müssen wir auch haben.1999). This was rapidly taken
up in the debate by some doctors to estimate the costs of running accreditation in the hospitals of
Copenhagen would amount to 80 million Kroner (in 1999 value) (Akkreditering møder massiv
kritik fra læger, 1999). Others have estimated the costs per hospital to amount to the salary of two
full time quality managers and a half time person per department (Bagger, 2012).
These objections raised by quite powerful interest groups may make one wonder, why hospital
accreditation was introduced in Denmark. The fact that accreditation is to be found neither in
Norway nor in Sweden only makes the Danish case even more puzzling (Shaw, 2006, p. 267; Shaw,
Kutryba, Braitwaite, Bedlicki, & Warunek, 2010, p. 343). Accordingly, this paper seeks to shed
light on the question: How can we understand the emergence of accreditation in the Danish hospital
system? This rather general question is broken down into three more specific ones. First, why did
the Danish health authorities decide around 2002/03 to develop the DDKM model instead of
adopting an existing model? Second, why was accreditation at all introduced in the Danish
hospitals? Thirdly, why did the quality of hospital services emerge as a pressing political issue?
2
Following a reverse chronological order, I first examine why the Danish health authorities decided
around 2002/03 to develop the DDKM model rather than simply adopting other existing models.
Both systems communication and rational actor theory seem to provide viable explanations. This is
followed by an analysis of why foreign accreditation models were voluntarily introduced in the
Danish hospitals around 2000. Here rational actor theory and to some extent neo-institutional theory
provide important insights. Finally, I try to answer why the management of the quality hospital
services emerged at all during the 1980s by using Foucault's analytics of government assemblages.
The paper essentially argues that DDKM was introduced in favour of other accreditation models
because the Ministry of Health, rightly or wrongly, assumed it would minimize resistance from the
medical profession. Accreditation was taken up by Danish hospitals because other ways of
managing quality had proven insufficient. Finally, the emergence of hospital quality as problem
calling for political intervention during the 1980s was conditioned on government assemblage made
up by new ways of registering, computing and comparing hospital services, their costs, and the
complaints they received.
2 Why was a mandatory Danish accreditation model developed?
In 2001, the Government agreed with the counties to initiate the development of a compulsory
model of accreditation pertaining to all public Danish hospitals (Amtsrådsforeningen, 2001). While
two (different) accreditation systems had recently been adopted by the Capital’s Hospital
Association and the County of Southern Jutland (see below), this was the first time that steps were
taken to that would force all hospitals to go through accreditation. Moreover, the Minister of
Interior and Health announced in the new national strategy for quality development in the
healthcare sector that Denmark needed a uniform, national model (Det nationale råd for
kvalitetsudvikling i sundhedsvæsenet, 2002). Logically speaking, a (nationally) uniform model
does/did not exclude the possibility that one of the two (foreign) models already in use was adopted.
However, in the spring 2002, a working group with members from the Ministry of Interior and
Health, the Board of Health, the Association of Counties, and the Capital’s Hospital Association
was established with the task of developing a national model. The guide for the design of the
national model did not explain or emphasise the need to incorporate foreign/international models
(Sundhedsstyrelsen, 2004). And in a policy note produced by the working group, it soon became
clear that the national model did not entail the existing models, but rather the development of an
entirely new model tailored to the Danish context (Indenrigs- og Sundhedsministeriet,
Amtsrådsforeningen, & Hovedstadens Sygehusfællesskab, 2003). This policy note also made clear
that the development of the new model should incorporate existing quality measures in the Danish
healthcare system and be based on extensive consultation with the various parts of the medical
profession.
Accordingly, a lengthy process of consultation with and inputs by virtually all parts of the medical
profession was initiated. In order to spur the process, which was losing momentum, the Institute of
Accreditation and Quality in Health Care (IKAS) was established in 2005 with the sole task of
ensuring the development of DDKM. Representatives from the medical profession were richly
represented in the thematic groups elected by IKAS with the crucial task of formulating suitable
standards for the model. Even with this renewed momentum, the process dragged on as two
3
versions of the models with all their hundreds of standards went through hearings and pilot tests.
Both hearings (spring 2007 and early 2008) resulted in quite extensive criticisms from various parts
of the medical profession who worried about the numbers and suitability of the standards and, more
generally, about certain methodological problems of the model. These criticisms resulted in minor
modifications of the model, which was then introduced at all Danish hospitals in August 2009.
Rational actors ..
One way of approaching the introduction of accreditation in Danish hospitals is by studying the
strategies adopted by more or less well organized interest groups in their rational pursuit of selfinterest.4 In a number of publications Kragh Jespersen has examined the role played by the medical
profession vis-à-vis public health authorities and the top hospital management in the development
of quality assurance mechanisms in the Danish healthcare system (Jespersen, 2001; Kirkpatrick,
Jespersen, Dent, & Neogy, 2009). A recurrent argument in these analyses is that the medical
profession has been quite successful in shaping the quality assurance measures adopted over the last
two decades. This influence has facilitated by a context of widespread local autonomy in the public
health sector, where the central government has mainly relied on agreements with the
counties/regions rather than laws. From the formulation of the National Strategy for Quality
Development in 1993 over the development of clinical databases and the indicator project to the
development of the DDKM, the doctors have had significant influence (Jespersen, 2008, pp. 12-15).
While the DDKM may ultimately result in reducing the autonomy of the medical profession, the
latter had substantial success in shaping the model’s design. Ultimately, it is this sustained influence
combined with the possibility of local decoupling from quality procedures deemed medically
irrelevant that may explain the medical profession’s acceptance of quality assurance measures
proposed by the health authorities (Jespersen, 2001).
The rational actor approach may also shed light on the strategies adopted by the public health
authorities in developing DDKM. Thus, the decision to develop a Danish model rather than
adopting the JC model or some other foreign standard could be seen as a way of reducing
resistance. By allowing the Danish medical profession significant influence on the design of the
model, the Ministry would effectively undermine concerted resistance against accreditation. Also,
as argued by one key informant, by not adopting one of the two different models already in use in
the Capital’s Hospital and the County of Southern Jutland, the Ministry avoided accusations of
favouritism (Bagger 2012). In sum, the rational actor approach provides valuable explanations to
the political processes leading to the development of the DDKM. However, while the rational actor
approach may provide insights into the countries decision to voluntarily adopt accreditation, it does
suffer from the conceptual problem that it is difficult if not outright impossible to talk about the
medical profession in terms of a consistent self or interest group. Not only were some parts of the
medical much more critical than others, the various sub-groups and even persons changed their
mind significantly in the process. These developments may perhaps better be captured by paying
attention to shifting systems of communication.
.. or systems and their communication?
Niklas Luhmann’s systems theory have served as inspiration for at least two analyses of the
political processes revolving around the DDKM by viewing these as distinct forms of
communication. First, Brandum et al have analyzed the forms of communication employed in the
decision-making process between 2002 and 2008, which lead to the implementation of the DDKM
(Brandum, Pedersen, & Ottesen, 2010). They show that the intentions behind the DDKM went
through several significant displacements during the policy process. They also show that the
4
medical profession was excluded from the last part of the process, which included the "final" design
of the DDKM. By implication, the form of communication meaningful to medical staff was partly
displaced by managerial considerations. Above all, the medical profession lost control over the
design and numbers of standards and indicators to be adopted. The analysis is interesting because it
shows how IKAS' more or less conscious (procedural) control of the policy process served to shape
the policy output, i.e. the exact design of DDKM.
Knudsen's account of DDKM as a technology of observation or visibility device, while also inspired
by Luhmann, seeks to make a rather different point (Knudsen, 2011). His major argument is that
such devises not only create new visibilities, but also new invisibilities or blindness. DDKM, he
argues, creates a self-imposed blindness to information that is potentially destructive to its survival.
This production of blindness is thus an organisational (IKAS') defence mechanism against a hostile
environment, notably the medical profession. Like the analysis by Brandum et al, Knudsen's
argument reads like a systems theory version of power exercised as agenda control. While the two
analyses eschew the actor-oriented approach found in Bacrach and Baratz' second face of power
(Bachrach & Baratz, 1962) and in March and Olsen's organization of attention (March & Olsen,
1995, pp. 116-118), the point made is not very different. Thus, the political struggle over the
DDKM may be viewed in terms of the systemic production and control over the information and
issues entering the decision-making process.
Of course, these two analyses do not exhaust the analytical potential of Luhmann's systems theory.
This theory could have been applied more head on to the question of the emergence of DDKM by
viewing the latter as an attempt to establish a structural link between two or more systems of
communication. In casu, this would entail analyzing how systems of administrative power (in which
the principal codes are right/not-right and efficient/not-efficient) have tried to link to systems of
medical science (in which the principal code is true/not-true). As testified by the medical
profession's incessant demand for scientific evidence for the efficacy of DDKM, much of the
conflicts that have evolved around the attempts to develop quality assurance systems in the
healthcare sector can be grasped in the light of distinct forms of systemic communication.
At any rate, we may conclude that both the rational actor and the systems approach provide
valuable, albeit quite distinct, insights into the introduction of DDKM. The former by paying
attention to the interests guiding the Ministry of Health and the medical profession(s), and the latter
by unravelling the modes of systemic communication within which these interests were articulated.
3 Why was voluntary accreditation systems introduced in Danish hospitals?
Probably, the most important step taken in the way of quality assurance prior to the initiation of the
process leading to DDKM was the decision taken by The Capital's Hospital Association in
beginning of 2000 to introduce the US Joint Commission accreditation system to all public
hospitals in Copenhagen (HS: Ja til kvalitetscheck på sygehusene, 2000). The system, which was
implemented in 2002, received widespread attention not only in the medical profession, but also in
the Ministry of Health and the media. Moreover, the County of Southern Jutland decided in early
2001 to introduce another accreditation model offered by the British quality organisation Health
Quality Service. This was implemented in 2003.
5
Prior to the decision, the introduction of competing accreditation systems in Copenhagen and
Southern Jutland, accreditation had been the subject of intense debates. On the one hand, the Centre
for Evaluation of Hospitals and important parts of the medical profession, including the chair of the
Association of Medical Specialists, were fairly positive (Læger ser frem til karakterbog, 1999). On
the other hand, many medical professionals including the chair of the Danish Medical Society
strongly opposed the decision on the ground of its expected high costs and unsure results in terms of
clinical improvements.
The often quite vociferous debate about the quality of hospital services had begun long before the.
Back in 1991, a specialist at the Nykøbing Falster Hospital launched a devastating critique of the
poor quality of Danish hospitals in general and his own hospital in particular, and maintained that
he would not like to be a patient in a Danish hospital (Sygehus til kamp mod fejlbehandling, 1991).
The following year, a much publicized case of erroneous hip surgery of more than 120 patients at
Aalborg Hospital had intensified the debate over the need for systematic reviews of hospital quality
(Kontrol med operationer, 1992). Simultaneously, the medical profession inaugurated The Council
for Medical Quality Assurance in the Healthcare System (Gøtrik, 1992). While the Council
acknowledged the need to strengthen quality assurance mechanisms, it was adamant that this should
not entail fixed, bureaucratic standards enforced by a 'police corps', which would only serve to
demotivate the medical staff (Kontrol løser ikke sygehuse-problemer, 1992).
Shortly after this quite intense debate over the quality of the Danish hospital system, the
Government launched the first national strategy for quality development in the health care system
(Sundhedsstyrelsen, 1993). Modelled after WHO/EURO, the quality strategy contained four
components: high professional standard, effective resource use, minimal patient risk and integrated
patient care. The Government was quite unclear on just how these components were to be put into
an operational system. Notwithstanding this lack of specificity, the strategy did spur a number of
voluntary initiatives, such as local user satisfaction surveys, procedures for better dialogue with
patients, and the development of national clinical databases (Sundhedsstyrelsen, 2000). More
importantly, the Government's decision in 1992 to introduce patient choice between the public
hospitals contributed to a more or less permanent public debate on the need for the disclosure of
information allowing patients to compare the quality of the various hospitals. However, a mixture of
technical obstacles and sustained resistance from parts of the medical profession meant that such
data would only be available from 2006 (www.sundhedskvalitet.dk).
In the early 1990s, the political debate over how to best manage the quality of hospital services was
linked to the drive to secure citizen choice of public services. For some years, the Consumer
Council had made its own surveys comparing hospital services and argued for more choice and
more information about hospital services in order to facilitate that choice (e.g. Forbrugerrådet,
1990). With the introduction of hospital choice in 1993, the demand for more and better information
about hospital services increased. The consumer council, patient groups and even many doctors
started to support the publication of data on variations in frequency of operations, clinical errors,
waiting times, etc. Patients had been able to complain over medical malpractice since the
establishment of the Patient's Complaint Board (Patientklagenævnet) in 1988. While this did entail
a form of monitoring of hospital quality, the information only came long after the fact. More
importantly, there was absolutely no guarantee that the hospitals would change their practices and
improve their services. Instead, patient choice of hospitals would send an immediate signal to the
each and every hospital and strongly encourage them to improve those services where patients
decided to go to other hospitals. If not, they would risk reductions in government payments, which
6
would gradually be based on the number of patients treated. After long negotiations, this quest to
ensure informed patient choice resulted in development of regular national user satisfaction surveys
both from 2001, and since 2006 the webpage www.sundhedskvalitet.dk containing - at least ideally
speaking - updated comparative data on the quality of hospital services.
The data published on www.sundhedskvalitet.dk seek to expose differences in clinical treatments
and enable informed patient choice. This, in turn, was envisaged by the Ministry of Health in the
early 1990s to make hospital (departments) compete on delivery better quality (Vrangbæk, 1999).
Yet, patient choice never managed to bring about significant improvements in quality development.
One obvious reason for this lack is that very few patients actually used their right to choose a
hospital different from the one assigned to them by default (ibid). Moreover, it has proven much
more difficult than expected to provide reliable data that in a meaningful way allow patients or
other citizens to compare the quality of hospital services.
The continued development of other quality assurance mechanisms, such as reference programmes
(early 1990s), clinical databases (early 1990s), the national indicator project (2001) and, ultimately,
accreditation attests to the view that the Ministry of Health and local hospital managements found
patient choice inadequate. It was seen as necessary to install procedures that would force medical
staff to abide by certain quality standards in their everyday practices. Reference programmes, the
clinical databases and the national indicator project were necessary but insufficient steps toward this
meeting this ambition. On the one hand, they provided many of the clinical standards and indicators
necessary to measure and manage quality. On the other hand, they did not ensure that medical staff
actually adopted these standards in their everyday practice. Only accreditation promised to ensure
that all medical staff at all hospital departments actually utilized the accepted clinical standards.
When the head of research at the DSI diagnosed the quality activities at the Danish hospitals as
temporary and fragmented quality (So ein ding müssen wir auch haben.1999), the suggestion was
that accreditation would ensure durable and coherent quality development according to the highest
national standards.
Rational actors again ..
The rational actor may again provide a valuable contribution to understanding why the Capital’s
Hospital Association and the Southern Jutland County decided to introduce accreditation. After a
decade of intense pressure from the central government, the media, the national consumer
organisation and patients, the decision to implement a system promised to ensure that medical staff
would actually abide by standards of clinical conduct in their everyday work does seem very
rational. While this decision to introduce accreditation was met with widespread resistance from the
medical profession, it may be regarded as rational in at least two senses. First, in the negative sense:
the decision enabled the Capital’s Hospital Association and the Southern Jutland County to
accommodate public criticism. Moreover, by acting as first movers, both actors may have hoped to
either avoid or at least shape the design of future interventions taken by the Ministry of Health. That
this strategy turned out to fail does not make it less rational. Second, the decision was rational in the
positive sense that the Capital’s Hospital Association and the Southern Jutland County could profile
themselves – vis-á-vis- the other counties as cutting-edge organisations in the area of quality
management. According to a key informant, this played a certain role in the case of the Capital’s
Hospital Association (Bagger, 2012). In sum, the rational actor approach may provide insights into
the countries decision to voluntarily adopt accreditation. Yet the approach has little if anything to
say on the choice of accreditation models. In order to grasp this, we may turn to neo-institutional
theory.
7
.. and isomorphic pressure?
Considering that Denmark – together with Norway and Sweden - is an international laggard with
regard to hospital accreditation, it would make sense to examine the role of isomorphic pressures
(DiMaggio & Powell, 1983). It seems fairly obvious that the WHO's health strategy 1984, which
urged all members to adopt quality assurance mechanisms, contributed to shaping the quality
agenda in the Danish health sector. Also, the longstanding experiences with healthcare accreditation
in the US, Canada and Australia (Scrivens, 1995, pp. 14-27) may very well have contributed to
convincing Danish health authorities that this may be the way to go about quality assurance. The
Capital's Hospital Association decision to introduce the US Joint Commission model and the
Southern Jutland County’s decision to introduce the British Health Quality Service modes testifies
to concrete influence. However, at least one thing speaks against the isomorphic thesis: quality
assurance systems in hospitals were debated at least since the late 1980s and were followed by the
development of several quality systems that had little if anything to do with accreditation. Most of
these systems continue to operate today in parallel with accreditation. Finally, we may note that
while the isomorphic thesis goes some way at explaining Copenhagen’s and Southern Jutland’s
voluntary introduction of existing US and British models, it is not very useful in explaining the
development of the DDKM. If mimicking existing models provides legitimacy and sticking out
from the crowd does not, then why did the Danish government decide to develop a new model more
or less from scratch? Perhaps it is fair to talk about selective isomorphism explaining why various
international accreditation models were voluntarily adopted by some Danish hospitals, but not why
the Ministry a few years later decided to have a specific Danish model developed.
In brief, the rational actor approach and the isomorphic pressure thesis both provide valuable clues
to explaining the introduction of voluntary accreditation systems. The former by unravelling the
political pressures mounting on the counties during the 1990s, and the latter by pointing to the
legitimizing force of adopting internationally accepted models.
4 Why did the quality of hospital services emerge as political issue?
In the preceding sections, we have tried to explain the development of a mandatory Danish
accreditation model and the introduction of voluntary accreditation systems. It is now time to turn to
the question of why the quality of hospital services emerged as a political issue in the first place?
The approaches used so far have had little if anything to say on this question. For example, Kragh
Jespersen’s otherwise insightful analysis of the politics of quality management in Danish healthcare
succumbs to the rather vague suggestion that the emergence of hospital quality as a topic of political
problematization was the result of influences outside Denmark (in the shape of WHO’s 1984 health
strategy) and/or outside the public sector (the total quality movement invading the private sector
during the 1980s). (Jespersen, 2001, p. 34). Similarly, Albæk’s neo-institutional inspired analysis of
how 'ideas' like quality circles, clinical teams and standards were introduced and translated into
healthcare practices simply note that these ideas were adopted from the quality ideas circulating in
the private sector during the 1980s (Albæk, 2009, p. 221)
A government assemblage?
As shown above, a common feature of most existing analyses of hospital accreditation and quality
management in Denmark is that they start by locating ideas, intentions or forms of communication
8
and then illuminate how they are transformed by agents into practice. To explain something is to
unravel a line of causality from idea or intention over a range of different agents' transformations of
these into concrete action. In order to avoid the problems linked to assuming the existence of given
selves, agents or even agency, I will take a rather different approach inspired by Foucault's notion
of dispositif or assemblage (Foucault, 1980, p. 194). This essentially entails that we look for
explanation not only in the realm of ideas, intentions and discourses, but also in that of material
practices, such as procedures of administration, techniques of classification and instruments of
measurement. Rather than trying to pin down - probably in vain - whether one of these elements
served as the determining factor, I think we may get a more nuanced and concrete understanding of
the introduction of hospital accreditation by accounting for the ways in which these ideational and
material practices at a certain point in time came to inter-relate to form a more or less consistent
policy assemblage (see also Finlayson, 2011, p. 550; Triantafillou, 2012, pp. 13-15). By adopting an
analytics of government assemblages, it becomes possible to shed light on one of the most
fundamental events that initially sparked and subsequently enabled and structured the political
process over the quality of hospital services. It should be noted that the term government refers here
not to “the government” – the state apparatus or institutions – but to the forms of thought and set of
practices whereby government is exercised (Foucault, 1991; Rose & Miller, 1992). In brief,
government denotes, on the one hand, the forms of thought, theories and knowledge about that
which is governed, and, on the other hand, the concrete procedures, tools and techniques employed
in the exercise of government.
From 1980 to 1988 an assemblage emerged made up by four elements: new methods of
categorization, computerization, cost concerns and complaint registration. Until the mid-1970s, the
registration of operations and other medical activities at the hospitals had been rather unsystematic
and very cursory (Sundhedsstyrelsen, 1964/65-1974/75). The quality of the medical services was
above all secured through a combination of state approved education and certification of the various
types of medical staff and rigorous testing of pharmaceutical products, surgery techniques and
medical technology (Juul, 1988). All this was to change, or at least importantly supplemented, with
the development of the National Patient Register in 1980, which contained a joint register of all
patients treated at the somatic hospital departments in Denmark.5 Simultaneously, the categorization
of operations was made much more detailed by greatly expanding the number of specific types of
examinations and operations. By combining the information of the National Patient Register with
the new detailed classification of treatments, it became possible to produce surveys comparing the
frequency with which each hospital conducted particular operations (Sundhedsstyrelsen, 1980).
Second, with the introduction of digital data processing, it became much easier to undertake
systematic comparison of all Danish public hospitals with regard to the frequency of specific
medical examinations and operations (Sundhedsstyrelsen, 1984). Within a few years of the
disclosure of these data both medical staff and health authorities (Bay-Nielsen & Jørgensen, 1985),
and economic experts inside the government (Lotz, 1987, pp. 87-91, 101-102) started wondering
why identical diseases were treated so differently in various parts of the country. Concerns were
quickly raised not only over potentially economically wasteful practices, but also over the variable
clinical quality of hospital services. Over the next years, this debate resulted in the development of
so-called reference programs by the Ministry of Health containing guidelines for the treatment of a
(limited) number of specific diseases (Sundhedsstyrelsen, 1992b, p. 5). It also sparked a number of
local experiments at the hospitals to improve and better integrate the treatment of individual patients
before, during and after their stay at the hospital by introducing a number of new procedures across
9
the various types of medical staff and specialties (Patienterne kræver kvalitet, 1991; Hammershøy,
1993; Hammershøy & Worning, 1991).
Thirdly, the particular Danish development was shaped by concerns over the costs of the public
health services. In the report by the Lotz committee on public expenditures and steering
possibilities, the variations in the frequency of operations conducted at the Danish hospitals was
specifically mentioned both as a potential problem of clinical quality and a definite problem of costeffectiveness (Lotz, 1987). Efforts had to be made to minimize these variations which were seen to
constitute a potential problem for clinical quality and an actual problem of cost-ineffectiveness.
However, as noted with surprising frankness by the committee:
The central problem regarding the governing of the use of resources and expenditures
is the problem with the doctor's right to apply his personal judgment in the treatment
of the individual patient (ibid. p. 98, my translation).
Much of the ensuing efforts to development quality assurance mechanisms had to with inventing
new forms of governing that shaped the conduct of doctors and hospitals in ways that did not arouse
resistance. More precisely, they had to be governed by laws and regulations, nor even by large-scale
voluntary agreement, though the latter did play a certain role. Rather, they had to be governed
through a variety of techniques and measures that would monitor, compare and ultimately publish
the quality of their performance. Thereby urging doctors and hospitals to take initiatives by
themselves to monitor and constantly improve the quality of their services. In more general terms,
this could be seen as reflexive government or the governmentalization of government whereby
attempts are made to govern those that govern (Dean, 1999, pp. 194-196; Triantafillou, 2012, pp.
170-171). In casu, regions, hospitals and doctors charged with the task of governing the health of
citizens, were not subjected to interventions seeking to activate them, i.e. urge them to constantly
think about how to govern better.
The Lotz committee may have been the most important but certainly not the only one explicitly
linking the governing of economic efficiency with concerns over clinical quality. At the first
national conference on healthcare quality involving other scientists than strictly medical one, it was
noted by a hospital director that the measuring of the quality of healthcare services not only implied
strictly clinical indicators, but also concerns over cost-effectiveness in the sense quality entailed
maximizing the clinical improvement of a population, rather than an individual, that could be
achieved with a given amount of resources (Pedersen, 1988). Similarly, the Board of Health made it
clear that quality development implies the setting of standards that are ’realistic quality measures
given the actual (local) conditions’ (Sundhedsstyrelsen, 1992a, p. 16, my translation). Quality
standards within healthcare designate not that which medically speaking may constitute the best
possible form of treatment, but those forms of treatment that given the economic, organisational and
other pragmatic concerns are the best possible.
Fourthly, the inauguration of the national Patient Complaint Board (Patientklagenævnet) in 1988
had important influence on providing attention to the (often failing) quality of hospital services. The
primary aim of the Board was to treat patient complaints and pass judgement on these complaints.
However, the most important effect in the present case was its annual reports on the number and
types of complaints. Over the next few years these reports, which tended to display a more or less
constant growth in the number of complaints, was taken by the media, concerned citizens and,
ultimately, politicians as a sign that hospitals had a problem with the quality of their services (e.g.
10
Patienterne kræver kvalitet, 1991; Flere og flere patienter klager, 1993). Accordingly, hospitals
were urged by county politicians, who in turn were under pressure from the Ministry of Health, to
take steps to ensure a better management of the quality of their services. Again, then, a new
technique for compiling, registering and publishing data – in this case patient complaints over
hospital services – produced a new form of visibility contributing to the problematization of the
quality of hospital services and their (inadequate/lacking) management. This is not to say that
patient complaints did not exist or were not important for the political debate over hospital services
before 1988. However, with the standardization, systematization and quantification of complaints, it
became possible to focus the political debate on particular hospitals, particular types of treatment
and particular types of hospital procedures. In particular, the latter cleared a space for addressing
the problems with hospital services in terms of inadequate management ensuring that clinical
procedures are monitored and actually enforced on an everyday basis.
In sum, the emergence of an assemblage consisting of new forms of categorization,
computerization, cost concerns and complaints registration served to render the issue of quality
amenable to a quite concrete problem amenable to more or less systematic governing. In particular,
the introduction of electronic data processing in the registration of patients leading to the national
patient register6 in 1980 combined with the vastly updated national classification of operations were
the sine qua non for the political game over quality management. Whereas the regional distribution
and variation of disease incidents (population epidemiology) had been registered for a long time,
the new technologies and classifications enabled a new form of knowledge, organisational
epidemiology. This organisational benchmarking avant la lettre essentially entailed comparing the
frequency with which all Danish hospitals conducted particular types of examinations and
operations. When added by concerns over costs and the systematic registration of complaints, a
whole new field of visibility emerged in which the differences between the hospital's way of
treating the same types of diseases could be turned into a problem of both of economic costeffectiveness and clinical quality. The emergence of the political of quality management at the
Danish hospitals thus emerged on the basis not on some fuzzy ideas about quality circulating in
"society", but on the basis of a set of specific, technical innovations that turned the problem of
quality into a concrete issue that could be objectified, quantified and compared.
Conclusion
This paper has examined why hospital accreditation was introduced in Denmark in the face of the
quite substantive economic cost related to its operation and the persistent resistance from large parts
of the medical professions. This rather general question was broken down into three more specific
ones. First, why did the Danish health authorities decide around 2002/03 to develop the DDKM
model rather than adopting other existing models? I have argued that DDKM was introduced in
favour of other accreditation models above all because the Ministry of Health, rightly or wrongly,
assumed it would minimize resistance from the medical profession. Existing analyses of the
development of the DDKM have used quite different theories to reach more or less the same
conclusion. The rational actor approach has been used to illuminate the ways in which the Ministry
of Interior and Health have tried to govern by allowing a certain level of discretion to and
participation of medical interest groups, and the systems communication theory have informed
analyses exposing the Ministry’s more or less subtle agenda control in the ultimate phases of the
design of the DDKM.
11
Second, I examined why accreditation was voluntarily introduced at in the Danish hospitals around
2000? I have tried to show that accreditation was taken up by the Capital’s Hospital Association and
by the County of Southern Jutland because other ways of managing quality had proven insufficient,
because it would enable them to portray themselves as national spearheads in healthcare quality
management, and because it could potentially pre-empt national, compulsory regulations. Again,
the rational actor approach may be fruitfully applied to explain the actions of the two organisations.
But also the isomorphic thesis, which assumes that organisations will mimic solutions that for some
reason have (professional) status, seem to hold a certain level of explanatory value.
Finally, the paper has examined why hospital quality management emerged as a pressing political
issue. In a certain sense this is the most crucial of the three questions. If the quality of hospital
services had not turned into a problem deserving political intervention, then the two proceeding
questions would have been irrelevant. In trying to answer this question, rational actor, systems
communication and institutional theory seem of little use. Either they simply take the problem of
hospital quality for granted or they point to ideas of quality that somehow diffuse into and
subsequently circulate in Danish society. This suggestion is simply too vague or abstract to serve as
an explanation. Instead, I have adopted Foucault’s notion of assemblage to show how a specific
assemblage around the governing of the quality of hospital activities emerged in Denmark during
the 1980s. The slow and often quite surprising development of connections between electronic data
processing systems, the CPR system, the standard classification of operations, problematizations of
public health expenditures, the systematic registration of patients’ complaints over healthcare
services served to provide a field of visualisation and intervention in which accreditation was an
obvious, albeit not a necessary, response. If we want to understand the techniques enabling and
shaping the political struggle over accreditation, rather than just taking the former for granted, then
we are best served by the analytics of government assemblages first suggested by Foucault. By
accounting for the elements of this assemblage and how they came together, we are offered an
understanding of why quality management in general and accreditation in particular seemed such
obvious answers to a problem that was not given at all until the formation of the new assemblage.
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Notes
1
The current accreditation model contains four steps, namely start up, self-evaluation, external survey and
publication (http://www.ikas.dk/DDKM/Processen.aspx). The first time a hospital is going to be accredited,
it is offered training courses by IKAS on the process. Once the hospital has implemented the standards, the
hospital is recommended to undertake a self-evaluation. This includes a systematic review of the extent to
which the actual medical and organizational practices and procedures are in line with the DDKM standards.
14
After a year or so an external survey is conducted. This implies a visit by a survey team of external medical
staff (selected by IKAS) who will interview hospital staff and patients, observe procedures and check
guidelines and documents. The survey-team then writes and publishes an evaluation report and recommends
whether the hospital should be approved, approved with remarks or not approved. If the hospital cannot be
approved at all or only with remarks, it is subjected to a re-survey focusing specifically on those elements
that were not in line with the standards. As of August 2012, 61 out of 66 Danish hospitals have the status of
accreditation without remarks. The last five have been accredited with remarks
(http://www.ikas.dk/Afgørelser/Sygehuse.aspx). So far no hospitals have been disapproved. After three
years, steps two to four in the process must be repeated.
2
As of August 2012, DDKM also embraces general practitioners, ambulance services, most pharmacies and
a range of municipal health institutions. There are also plans for including specialist practitioners and
dentists.
3
Accreditation is usually defined in more or less the following manner: a process whereby an (professional,
NGO or public) grants recognition to an institution for demonstrated ability to meet predetermined criteria
for established standards (e.g. http://medical-dictionary.thefreedictionary.com/accreditation).
4
This argument takes its cue from the thesis of regulatory capture, i.e. the explanation of public regulation in
terms of its capture by private interest groups with a view to accommodate the interests of the latter (for and
overview: Mitnick, 2011).
5
LPR initially only registered somatic treatments and certain examinations carried out on hospitalized
patients. Out-patients were only included from the late 1980s.
6
Again, the national patient register could only be developed because of the Central Person Register
established in 1968. This register contains a unique code number for all persons living in Denmark together
with data on name, birth date, address, employment, marital status, right of voting, etc.
15