Background: Conceptualization of quality of care – in terms of what individuals, groups and organizations include in
their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as
a means to successfully implement improvement efforts and bridge potential disconnect in language about quality
between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization
of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within
clinical micro systems (micro level) in a cross-national study.
Methods: This cross-national multi-level case study combines analysis of national policy documents and regulations
at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings
and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the
Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month
period (2011–2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care,
intensive care, and geriatrics).
Results: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated
in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included
efficiency and costs in their conceptualization of quality. ‘Quality’ in the forms of measuring indicators and performance
management were dominant among senior hospital managers (with clinical and non-clinical background). The differential
emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the
micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience
was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied
between micro systems depending on the type of services provided.
Conclusion: The quality conceptualization differed across system levels (macro-meso-micro), among professional
groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals.
This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.