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Why Adopt ISO 9001 Certification in Hospitals? A Case Study of External Triggers and Sensemaking in An Emergency Department in Norway

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Johannesen and Wiig Safety in Health (2017) 3:7

DOI 10.1186/s40886-017-0058-5

RESEARCH ARTICLE Open Access

Why adopt ISO 9001 certification in


hospitals? A case study of external triggers
and sensemaking in an emergency
department in Norway
Dag Tomas Sagen Johannesen1,2* and Siri Wiig3

Abstract
Background: Certification and accreditation are widely used to achieve quality and safety in health care but are also
questioned regarding their assumed effects. This is a challenge for policymakers and managers, since adoption of these
regimes can have a circumstantial impact upon organizations. This study’s aim was to explore how external conditions
catalyzed and triggered organizational change and internal sensemaking processes as part of an ISO 9001 certification
process.
Methods: The study applied an explanatory single-case design, using a narrative approach, to retrospectively follow a
sensemaking process in an emergency department in a Norwegian hospital undergoing ISO 9001 certification.
The certification process was a pilot initiated by a Regional Health Authority, which ran from autumn 2008
until spring 2012. Nine semi-structured, qualitative interviews were conducted, and documents in the form of
minutes and reports were collected. The data was analyzed according to an organized sensemaking framework.
Results: The adoption of the ISO 9001 certification did not follow a comprehensive decision-making process. Our study
shows two external situational triggers that initiated adoption. First, a countrywide supervision conducted
by the Norwegian Board of Health Supervision concluded that inadequate management and leadership
negatively affected the day-to-day running of Norwegian emergency departments. This external disruption
visualized longstanding organizational challenges that threatened the managers’ shared identity. A search
for meaning became prominent. Second, an occasional, externally initiated certification project was a plausible
solution that would lead to an immediate action that would reduce uncertainty. Institutional requirements
and concepts in the international ISO 9001 standard and in the national health regulations were unfamiliar and
ambiguous for the project group involved in the certification. These issues became the institutional external triggers for
intra-organizational sensemaking processes that made ISO certification possible. External assessments were acknowledged
as useful for making improvements.
Conclusions: By combining institutional theory with sensemaking theory, this case study contributes to a better
understanding of how external pressure meets micro-level change processes. These understandings are important
because environments give rise to adoption of different management tools, such as certification, but organizations
adopting new management tools seldom abandon others. This can lead to even more complex health care.
Keywords: Certification, Accreditation, ISO, Quality improvement, Sensemaking, Organizing, Change, Institutional theory,
Narrative analysis

* Correspondence: dag.t.johannesen@uia.no
1
Department of Media, Culture and Social Sciences, University of Stavanger,
4036 Stavanger, Norway
2
Department of Health and Nursing Science, University of Agder, 4604
Kristiansand, Norway
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Johannesen and Wiig Safety in Health (2017) 3:7 Page 2 of 14

Background accreditation cycle, but concluded that more focus on


Accreditation and certification programs in health care continuous improvement methods to sustain the
are used internationally to ensure, regulate and drive qual- positive impact form accreditation was needed, for in-
ity improvement and safety initiatives. Starting as a profes- stance, frequently self-assessment or unannounced ex-
sional self-regulatory standardization and control initiative ternal reviews [15]. The use of unannounced external
in the early years of the twenty-first century, the number reviews was recently studied in a nationwide cluster-
of programs globally has grown tremendously in the last randomized controlled trial [16]. No difference
25 years. In Norway such programs have no clear history between announced and unannounced surveys in de-
other than some small ad hoc initiatives. At a national tecting non-compliance with accreditation standards
level, nationwide certification and accreditation programs in hospitals was found.
have been debated [1, 2] and were recommended by the The uncertain relationship between adaption of differ-
Government in 2015 [3]. Claims about a limited evidence ent accreditation or certification programs and quality
base and rigorous study designs of the effects upon recog- and safety objectives poses a challenge for policymakers
nized quality measures have been put forward in several and managers. Despite these challenges, hospital certifi-
international publications, especially in relation to how cation and accreditation are widely used and differ ex-
many resources are allocated to accreditation and certifi- tensively in their purpose and organization [10, 17].
cation systems internationally [4–6]. Recently, two up- Certification and accreditation can therefore be consid-
dated systematic reviews about the effects of certification ered as a legitimate and institutionalized means of regu-
and accreditation [5] or external inspections [7] upon lation of quality and safety in hospitals, and in complex
process or clinical outcomes only found respectively one organizations they reflect contemporary tendencies of
and two studies that met their inclusion criteria. The means–ends decoupling [18]. In means–ends decoupling,
authors found no strong evidence to conclude about the ef- we see that the adoption of new policies or formal struc-
fectiveness of certification or accreditation. Earlier reviews, tures has a real impact upon change of organizational
with broader inclusion criteria report in general inconsist- activities and cultures, but there is limited evidence
ent findings on the relationships between certification and linking these changes to organizational effectiveness and
accreditation programs and clinical performance and outcomes (see Fig. 1).
outcomes, a positive trend about the programs ability to Figure 1 presents the questions about why complex or-
stimulate improvement work and promote organizational ganizations allocate resources to practices that have a
and cultural change and change in professional practice scarce or diffuse known relationship to organizational
concerned with quality of care, and contrasting views objectives. In hospitals, such objectives are most often
among professionals towards accreditation [8–10]. Studies linked to better outcomes of patient care. This case
of 89 European hospitals indicate that accreditation and study takes these questions into a hospital context in
International Organization for Standardization (ISO) 9001 Norway, and investigates why and how an emergency
certification are positively associated with some quality and department (ED) adopted and was certified in the ISO
safety structures and hospital outputs such as hospital 9001:2008 Quality management systems – Requirements
management, clinical practice, safety, patient-centeredness standard.
and cross-border patient-centeredness. These studies dem-
onstrated that accreditation has slightly more impact than ISO 9001 certification—what is it?
ISO certification, but either system is better than no exter- ISO 9001 certification can be seen as an external con-
nal assessment [11, 12]. The recent EU project DUQUE formity assessment or control mechanism to assure and
with data from 73 European hospitals studied the relation- regulate quality and safety in health care. It is often
ship between ISO 9000 certification, healthcare accredit- compared to or described interchangeably within the
ation, and quality management. The researchers concluded “family” of external assessment strategies for health care
that accreditation and certification were positively associ- organizations, and especially accreditation [19, 20]. The
ated with clinical leadership, systems for patient safety, and common purpose of these external assessment programs
clinical review, but not with clinical practice [13]. In a is to provide information and evidence that the
Danish nationwide population-based study the researchers organizational system and performance conform to a spe-
reported a lower 30-day mortality risk for admissions at cific standard, and both certification and accreditation pro-
fully accredited hospitals compared to admissions at grams award the assessed organization with a certificate on
partially accredited hospitals [14]. Using an interrupted successful conformity. Certification bodies and auditors
times series analysis following one hospital in Abu Dhabi should strive to build confidence and trust through a prac-
over 3 years, the researchers showed that the positive tice rooted in impartiality, competent assessments, and de-
impact of healthcare accreditation on hospital quality cisions based on objective evidence [21]. The ISO 9001
measures to some degree was maintained during the 3 years standard does not prescribe performance requirements.
Johannesen and Wiig Safety in Health (2017) 3:7 Page 3 of 14

Fig. 1 Possible means–ends decoupling for ISO 9001 certification in hospitals. The figure is adopted and modified from Bromley & Powell [18]

Rather, it proposes generic requirements for structures and Theoretical approach


systems that enable organizations to formalize production The rise in certification and accreditation practices in
or service processes into a series of procedures, and to con- healthcare [17] reflects the shifting mode in regulation
tinuously monitor, document and improve its efficiency (often a reduction in “hard laws” and directives), spread
upon customer (patients) requirements and legal regula- and diffusion of modern management tools, and de-
tions [22, 23]. An audit program has a 3-year audit cycle: mands for accountability and transparency in our con-
the initial certification process, two shorter “surveillance temporary society. In this case study, we treat the
audits” over the next 2 years, and then re-certification in interplay between the enforced internal control regula-
the third year. tions and voluntary ISO certification from the perspec-
tive of re-regulation [28] or decentered or plural
Aim and research question regulation [29]. Typical of such regulation is the trans-
The aim of this case study is to explore external condi- formation into modes of governance1; with or without
tions that may catalyze and trigger organizational change governments, often transnational in structure, and
[24–27], and internal sensemaking processes in the local represented by non-binding “soft” rules and regula-
ED management [24] that led to the continuity and tions. Such soft regulations are often diffuse and lead
change in favor of ISO 9001 certification. The following organizations to search for other means and control
research questions guided the study: mechanism [28, 30].
To study the interplay between mandatory regulatory
– How do external environments contribute to an demands in healthcare and the voluntary adoption of
adoption of ISO 9001 certification in an emergency ISO certification in a Norwegian hospital context, we
department? draw on the contributions of institutional and sensemak-
– How does the local management make sense of the ing theory.
certification process?
Institutional trigger
This paper reports on the sensemaking processes in an The present study emphasizes how macro institutional ele-
emergency department in a Norwegian hospital under- ments shape, trigger, or become situated by organizations
going ISO certification. By combining institutional the- and individuals, but with less influence over the continuing
ory with sensemaking theory, the paper contributes to a intra-organizational sensemaking processes [25, 27, 31].
better understanding of how external pressure meets a People act and then use institutional structures to give
local conceptualization of quality management processes meaning to their actions. This perspective breaks with more
in ISO certification. traditional perspectives where institutional environments
Johannesen and Wiig Safety in Health (2017) 3:7 Page 4 of 14

place cognitive constraints upon organizations and intra- accuracy and truth, but about plausibility. People continu-
organizational processes by preclusion of other alternatives. ally redraft their stories in their search for meaning, so the
According to Weber and Glynn [25], there are three mech- stories become more comprehensive and resilient to criti-
anisms in addition to traditional cognitive constrains cism, and richer in data. Important in our case study was
whereby institutional context affects sensemaking: priming, how a local project group constructed a story that we re-
editing and triggering. Institutional contexts, in their view, gard as collective shared meanings. Shared meanings is a
refer to both the external institutional environment and in- core theme for both crisis sensemaking and change sense-
stitutionalized structures or scripts within organizations. making [26].
People acting in situations extract cues to activate sense-
making processes. In this case study, we follow the trigger- Methods
ing mechanisms [25] which relate to how contradictions, In this section we will describe the regulatory context of
ambiguities, and gaps inherent in stable institutional struc- Norwegian hospitals. Then we continue with design and
tures create puzzles that require people to search for mean- data collection and present our analytical framework.
ing. For example, the Norwegian healthcare regulation and
the international ISO 9001 certification system represent Context and internal control regulation in Norway
different institutional structures that when adopted are sup- The Ministry of Health and Care Services has the overall
posed to constrain action. They also carry different legitim- responsibility for the specialized health care services in
acy mechanisms that when adopted in different Norway. Public hospitals are owned by the Government
organizational contexts have the potential to be ambiguous, and organized in four Regional Health Authorities
diffuse, or incomprehensible. (RHA).
The regulation of quality and safety for health service
Sensemaking, turbulence, and change providers in Norway is based on a functional legislation,
The sensemaking perspective [24, 31, 32] helps to see outlined as enforced self-regulation [34], where different
the micro processes that enfold when managers adopt regulatory requirements are based on an internal control
popular quality and safety programs, such as total qual- system [35]. Hospitals have in this perspective a great
ity management, six sigma, and LEAN management. deal of latitude to make decisions and set priorities
Adoption processes do not follow rational, instrumental about their organization and services [36].
decision-making processes, rather they are filled with All hospitals, their service and health personnel, are
constantly changing sensemaking processes in order to subject to supervision by the Norwegian Board of Health
give meaning to changing situations and outcomes Supervision (NBHS), through the 18 Offices of the
[31, 33]. Sensemaking is most evident when the world County Governors. The main supervision of hospitals is
is perceived to be different from its expected state or when performed as system audits, whose aim is to ensure and
there are surprises [31]. Such diversity is described as control whether health services are complying with na-
triggers or a discrepant set of “cues” [24] enacted by indi- tional acts and regulations. In practice it involves audit-
viduals. Cues can be small bits of information, events or ing the health service’s internal control system.
simple familiar structures, and people turn to earlier In 2005, a RHA voluntarily adopted the ISO 9001 as a
scripts, schemes, or frames to ascribe meaning to cues guide for all its hospitals, in order to operationalize the
and decipher the situation. In other words, people are internal control system requirements [37]. It was argued
guided by institutional constraints, organizational that an identified lack of follow-up on the internal con-
premises, plans, expectations, acceptable justification, and trol system could be connected with difficult conceptual-
traditions inherited from predecessors [31]. Weick [24] izations, vague demands, and uncertainties about overall
explains the sensemaking mechanisms that foster these quality management systems and its advantages [38].
organizational processes as thoughts, feelings, and inten-
tions, the “intrasubjective meanings”, being merged into Design
“intersubjective meanings” through conversations. In The present study is designed as an explanatory single-
times of stability, individuals draw on common scripts and case study [39]. For explanation building, we used a
frames to make sense of situations. But, in times of narrative approach [40–45] and storytelling [46] to
turbulence and change, these “old” scripts no longer work. retrospectively follow sensemaking during the local ISO
A gap needs to be filled and an intersubjective or collect- 9001 certification process of an ED in a hospital trust
ive sensemaking process again becomes prominent. in Norway. The process ran from autumn 2008 until
People look for reasons to continue or resume their work. spring 2012.
In the search for reasons, sensemaking is about the An overall story or narrative was produced during the
interplay of action and interpretation rather than the in- research process. It illustrates how those involved in a
fluence of evaluation on choice [31]. It is not about local project group collectively made sense of the
Johannesen and Wiig Safety in Health (2017) 3:7 Page 5 of 14

practices and experiences that unfolded during the certi- work; (2) the certification process and its results; and (3)
fication process. The stories and meanings that the in- how ISO 9001 standard and certification was understood
formants provide about past experiences can in itself be in relation to formal quality and safety regulations and
seen as a sensemaking process, as the nature of sense- management tools. Open questions were generally used,
making builds upon frames that continuously change as often followed by either preplanned or ad hoc probing
the informant act and acquires experience [24]. The nar- questions, in order to help subjects to recall and tell
rative can as such be seen as a co-construction between more detailed stories about the ISO certification process
the informants and the author (the researcher), in and their experiences.
addition to stories from documents (artefacts), and are
constructs through which events are made sense of Analytical framework and process
rather than just representations of these processes [40]. Organized sensemaking is primarily a process theory.
When conceptualized organized sensemaking can be
Sample and data collection treated as a sequence of “ecological change—enactment—-
The case study relies on data produced from qualitative selection [and]—retention [31]”. Ecological changes in this
interviews and documents [39, 47]. An initial explora- context are treated as both intra- and inter-organizational
tory interview was conducted in June 2011. Then docu- environments. In the organizing process of enactment,
ments and informants were selected for further study. people are shaped by environments and sense anomalies
Data derived from documents took the form of minutes that are “…triggered by discrepancies and equivocality in
of meetings and reports that were made available by in- ongoing projects, [and] begin to change the flux of circum-
formants and official websites (Table 1). The main data stances into the orderliness of situations” [31]. Selection is a
collection was performed during spring and autumn process of narrative reduction where possible meanings are
2012. reduced and generate a tentative and plausible story. In re-
Twelve informants were firstly purposefully selected. tention the plausible story is connected to past experience
All were managers and key personnel in the ED, head of and fit with identity, and such makes a new script or cogni-
clinical and service departments, key personnel in the tive frame that feeds back to the prior processes. In this
certification process, and the project management in the case study we have applied the following analytical categor-
Regional Health Authority. After conducting eight inter- ies, modified, and adopted from Steyer et al. [48], that aims
views (Table 2), a distinct picture of the key local project to emphasize the key elements in organized sensemaking
management for the certification process could be processes [24, 31, 49] (See Fig. 2):
drawn. The eight interviews revealed a distinct local or- Frame (retention): Involves cognitive frames (retained
ganizing and sensemaking process, especially that of the plausible stories, such as acquired from work, training
local project management (and the local ED manage- or life experiences) and formal frames (e.g., categories,
ment, since managers were represented in the project plans, procedures, organizational structures, and arte-
management). facts). Frames are sources of guidance for interpretation
Semi-structured interviews were conducted in June and action.
and August 2012, according to an interview guide and Cue: Information or event extracted from the environ-
centered upon three themes: (1) the subjects’ role, the ment by actors. People ascribe meaning to cues by relat-
organization, and aspects concerning quality and safety ing them to frames.
Table 1 Data sources—documents
Data source Type of document Year Document title
Norwegian Board of Health Report 2007 Report from supervision of adequacy and quality in the
Supervision - Office of the emergency department in somatic specialist health service
County Governor in xxx hospital
Norwegian Board of Health Report 2008 “While we are waiting….”—do patients receive adequate
Supervision treatment in accident and emergency units?
Regional Health Authority and Project description 2008 Accreditation in emergency departments “… for good and
Norwegian Accreditation equal health services”
Norwegian Accreditation Sector Report 2010 Report from the Norwegian Accreditation Sector Committee
committee P14 Emergency P-14 Emergency Departments
departments
Norwegian Accreditation Guidelines (including special or 2010 NA Doc. 59 Guidelines of ISO 9001:2008 for Emergency
extended scope of requirements) Departments
Emergency Department Minute 2010 Evaluation meeting about ISO certification of the emergency
department 08.02.10.
Johannesen and Wiig Safety in Health (2017) 3:7 Page 6 of 14

Table 2 Data sources—interview subject profiles


Formal position Role in the certification project Formal education
Head of Department, ED Leader of the local project group, and the Intensive care nurse, Master of
local pilot projects (EDs) representative in the Management
overall regional project organization
Head of Section, ED Member of the local project group Intensive care nurse, Master of
Management
Head of Unit-1, ED Member of the local project group Nurse, Ongoing (2012) Master of
Management
Head of Unit-2, ED Member of the local project group Emergency care nurse
Quality Advisor, Quality and Member of the local project group Nurse, Master of Management,
research department Quality studies
Project Leader, Regional Health Project leader in the overall regional project Nurse, Master of Health
Authority and focal point for the local pilot project in the Administration, Quality studies
emergency department
Head of quality and research Allocated personnel to the local certification Unknown
department project group
Head of doctors, Department of Managed doctors working in the Department Nurse
internal medicine of internal medicine

Discrepancy: Equivocality and discrepancies between the world. In this study the main actions are identified,
cues, and between cues and frames. It gives an occasion while acknowledging the challenge of simultaneously
to search for and reconsider a meaning. It is related to identifying both action and cognition [48].
the question “same or different” [31]. When a situation Our analytical process follows the principle of “narrative
feels different, it activates a search for meaning. analysis” proposed by Polkinghorne [50], incorporating
Concern: A tentative plausible story (e.g., an opportun- analytical features from Boje’s [45] causality analysis in an
ity, problem, perceived uncertainty, issue, or contro- antenarrative perspective. Our narrative follows the char-
versy) that the individual or group pay attention to. acteristics of a narrated plot [42, 45, 50], where beginning,
Action: Through action, people produce parts of their middle, and ends of the story come into being. Such retro-
environment and are “making” what is sensed [24]. spective reconstruction often starts with the outcome as a
People also enact what has been made sense of back into starting point for how this event came about. In this case

Fig. 2 Analytical categories. The analytical categories (shown in callouts) are used in this case study to emphasize the key elements in the conceptual
relationship among enactment, selection, and retention [31]. The figure is adapted from Jennings & Greenwood [66] and Weick 1979 [31]. Examples
from the present case study are put in parenthesis in each callout
Johannesen and Wiig Safety in Health (2017) 3:7 Page 7 of 14

study the guiding outcome was the ED’s adoption of ISO build upon or implement, and decided on the ISO
9001 certification. Our first analytical step was to arrange 9001:2008 Quality Management System - requirements
the data elements chronologically and construct a baseline standard, with its additional guidelines for use in health
story. The baseline story was modified in an ongoing services [23]. The main reason was that the ISO 9001
process along with a repeated reading of the interviews. In was in compliance with the current Norwegian internal
our next step we identified elements that are contributors control regulation. Two ED was chosen as pilots for the
to action and outcome [50]. Here the baseline story was project, in order to (1) identify core processes and risk
categories into our analytical framework (Fig. 2). Our final areas to specify new requirements for EDs and (2) be-
analytical step was an ongoing construction (writing, cat- come ISO 9001 certified and meet the new require-
egorizing, and rewriting) of the narrative into a temporally ments. One of the EDs ended the process before
patterned whole [50]. We have visualized in brackets the becoming certified, and the other, whose story is told in
categorization in the final narrative presented in this the next section, became certified in 2010 [53].
paper, to make the analytical process more transparent.
To ensure trustworthiness, the narrative, with its analyt- The initial phase
ical categories, was sent by e-mail to six of the informants, The ED had struggled for years with a heavy and chal-
who confirmed the narrative. Only slight changes in the lenging patient flow, and worked to improve the system
narrative were done after the informants’ responses. without acceptable results [frame]. During this time
there had been a change towards more attention to qual-
Results ity improvement and control, both through central, re-
The story of change gional, and local initiatives. The RHA had become more
The following story is presented in two stages. The first explicit on requirements about, among others, waiting
outlines the initial establishment of the external project time for patients, patient safety, and prevention of infec-
that initiated the pilot process in the ED. The second tions [frame]. The ED was also in the middle of a re-
narrates the intra-organizational sensemaking that con- building and merging process to take over the
tributed to continuity and change in favor of ISO 9001 emergency functions from another hospital. The volume
certification. of patients was high, they were kept waiting, and there
was not enough beds [concern].
Following up on unacceptable conditions in emergency The ED got two nonconformities from the country-
departments wide supervision that required managerial follow-up.
In 2007 the Norwegian Board of Health Supervision The first nonconformity pertained to the accumulation
(NBHS) carried out a countrywide supervision of 27 out of patients that could lead to failure of treatment; the
of 54 hospital emergency departments in Norway, and second was related to the examination conditions in the
concluded that in general, there was a lack of manage- ED, which did not ensure adequate protection of confi-
ment responsibility for ensuring that daily tasks were dentiality, patient integrity, and information exchange
planned, organized, carried out, and improved in accord- [cue]. The challenges in the ED were once again
ance with legislative requirements [51]. The NBHS de- highlighted [cue] and the hospital top management be-
scribed the situation as unacceptable and required the came more involved in resolving these challenges [dis-
management to take action. crepancy]. The ED once again started to look for
As a direct follow-up of this report the Norwegian Ac- solutions and make efforts to improve patient flow
creditation (NA)2 and one Regional Health Authority [action].
(RHA) initiated a collaborative project. Its objective was Some months after the report from the NBHS, the
to set a standard that EDs could use to ensure and im- hospital trusts in the RHA were asked to participate in
prove internal control and management systems, and for the pilot project. The ED was then asked by their hos-
accreditation or certification purposes [52]. A sector pital CEO [cue]. The Head of Department had a quick
committee3 including an administrative project organization, consultation with middle managers in the ED, and the
the regional project group (RPG), was established in the response was “Yes, let us jump on it” (Informant Y).
spring of 2008. They immediately decided to participate in the pilot [ac-
The sector committee was composed of representa- tion]. Their expectation was to get the assistance to
tives from all the RHA, NBHS, and other professional work systematically to resolve the challenges in the ED
experts, and their work took place from August 2008 [concern].
until March 2010. The new accreditation standard for The process in the ED started in autumn 2008. The
EDs was supposed to concretize the generic require- first meeting was represented by people from the hos-
ments in the legal internal control regulation. The com- pital who delivered services to the ED (e.g., physicians
mittee considered different management standards to and the X-ray department) in addition to people from
Johannesen and Wiig Safety in Health (2017) 3:7 Page 8 of 14

the regional project group. The intention was to anchor very much; however, they did the last part in order to
the project with concern to those departments that de- push us all the way to the end. (Informant Z)
livered services to the ED, and not just the ED in isola-
tion [concern]. Especially, the integration of physicians None of the LPG members had experiences [frame]
was considered important [concern]. The head of de- with ISO 9001 standardization and certification pro-
partment was the hospitals representative in the RPG cesses [discrepancy], except for one member of the qual-
and was highly involved in the development of the new ity department, who became an important “translator”
requirement for EDs during spring 2009. She also be- [cue] of the ISO standard during the pilot project. The
came a key actor and a primer for the local pilot standard needed contextual adaptations to be legiti-
throughout the project. mated in the ED [concern]. Terms like risk assessments,
During spring 2009, the ED established a local project measuring, monitoring, and recording are obvious
group (LPG) led by the head of department and three concepts and parts of an ISO quality management sys-
middle managers [action]. At that time they did not tems, but it was an unfamiliar terminology for the LPG
know what to expect, other than they would be assessing [discrepancy]. The additional ED requirements devel-
and describing processes, identification of system vulner- oped during the project became important concretiza-
abilities, and implementation of relevant actions in the tions of the ISO 9001 standard and the internal control
ED [discrepancy]. In any case, they immediately threw regulations. It generated a contextual translation [cue] of
themselves into the work, starting to describe processes rather general requirements [discrepancy] and so ordi-
and identify vulnerabilities [action]. After a while they nated a meaningful operationalization in the ED [action].
were made aware of [cue] that the pilot project would As “newcomers” [frame], the LPG needed concretization
involve the use of the ISO 9001 standard [discrepancy]. [concern].
Then they realized their need for local assistance about The LPG referred favorably to the certification body.
developing quality management systems [concern]. A In the first phase of preparing the ED for the initial
quality adviser from the Quality and Research Depart- onsite document review, there was a large amount of e-
ment integrated in the LPG [action]. The main work on mail between the ED and the certification body. The
ISO 9001 certification began in the summer of 2009. hospital received much advice and help on how to
improve the organization [cue]. The auditors were
The standardization and certification phase: summer– considered very detailed, sometimes almost too much
autumn 2009 [discrepancy], especially during document reviews and
The LPG worked enthusiastically and intensively, espe- the certification audit. At the same time the auditors
cially in July and August 2009. Most of the group mem- created confidence with their detailed knowledge and
bers worked extra to complete the work [action]. The ability to identify salient points and ask questions about
rest of the employees in the ED were less involved, limit- the documents and systems [cue]. They also transferred
ing their participation to some ad hoc working groups, experiences from other organizations and brought expert
such as those to establish and revise procedures. Even knowledge on systems and change processes. The LPG
though the LPG had agreed that the main intention for experienced the certification process more as guidance
the ED was to review their management systems [frame], than as control [discrepancy].
there seemed to be a clear awareness among the LPG It was a turning point for the LPG when they re-
members that the hard work on standardization con- ceived feedback from the certification body and
sisted of taking steps towards certification [concern]. gained experience from the standardization process it-
They had an opportunity for external help with improve- self [cue] that changed their understanding of systems
ment work, and this extra focus [cue] seemed to gener- that they had considered well-functioning: “things that
ate actions and a desire to demonstrate that they now we took for granted” (Informant Y), but were not
were able to succeed [concern]. good enough [discrepancy]. They started working dif-
ferently with their systems [action] which generated
[I]t was a combination of several things. […] When an improved overview of their organization and tasks
the crisis is big, it’s even more important to get things [cue], the number of procedures was reduced consid-
done. It’s a motivation in itself to do something—that erably [cue], and explicit objectives for improvement
was important. We were selected from the Regional was created [cue]. The latter was a shift from describ-
Health Authority to accomplish this—that was an ing objectives in general concerns, like “we should be
important element. […] It turned out just like a better at…” to develop measurable objectives that
competitive element, just like: ‘This is something could be monitored. The entire improvement and cer-
we can master’. Clearly, much was done before the tification process [action] was considered as an im-
certification body came in. We had been working portant help [frame].
Johannesen and Wiig Safety in Health (2017) 3:7 Page 9 of 14

The initial countrywide supervision pinpointed the requirements for EDs were not considered the optimum
responsibility of other professions, especially physi- way of organizing, but it was treated as one way, among
cians, to hold them accountable for the challenges in many others, that generated system improvement [frame]:
the ED [cue]. The emphasis on creating descriptions
and visualization of core processes in the ED [action] [T]he fact that we are ISO-certified—as I say: We have
made the department more visible and the process put some things in place; it is easier to find, easier to
was considered a key to the shared understanding breathe, you don’t need to doubt, you don’t have to
and commitment among leaders in other departments look; it is helping to create those secure frames. So
[cue]. The certification body drove this accountability that those who work within these frames are given
concern further, and mutual contracts with “service” the opportunity to flourish in the face of the patient.
departments (including physicians) was a requirement (Informant W)
for certification [cue]. “A milestone could be seen
when agreements with other heads of departments be- Even though the LPG considered the certification
came evident” (Informant X). process to imply system improvement [frame], they did
There were some worries among the employees in not expect that the employees would perceive quality
the ED about the perceived absence of management improvements, or associate system changes with the ISO
[cue], but the LPG did not enact any significant op- certification [concern], since the certification process did
position either inside or outside the ED [cue]. The not really affect the daily operations and patient treat-
fact that the ED was a part of the pilot project and ment. At least two other quality improvement initiatives
was supposed to [frame] organize for and deliver a (triage and nurses’ continuing education) were initiated
service that was certifiable [discrepancy] was regarded in parallel with the certification process, and these were
as an important driver, not just for the LPG but also considered to have more positive association with
for other professions outside the ED that participated improved treatment quality compared to the ISO certifi-
in working groups. It seemed that “no one” would cation [cue].
contribute to the failure of a certification status, espe- The ED underwent two yearly surveillance audits4
cially since it was decided at the top of the organization conducted by the certification body after the initial certi-
and as a direct follow-up of the external supervision fication audit. These external assessments were consid-
[concern]. ered important for sustainability of quality improvement
[cue], even though the management understood that
[T]he symbolic perspective of certification is just as quality improvement should be part of everyday practice
prominent as the rational. I believe that, and that’s my [discrepancy]. Whether these audits needed to be per-
conclusion. Much of the things that we initiate are formed by a third-party certification body was not con-
like that. Symbolic perspectives should not be sidered of major importance, and neither was the
underestimated (Informant Z). importance of the certificate in itself [Frame].
The ED management started to question the need for
After following up on the nonconformities that were further use of an external certification body [concern].
given during the certification audit, the ED finally re- These concerns were based on (1) negative experiences
ceived its first ISO 9001 certificate in January 2010. from the latest surveillance audit, where a new team
from the certification body conducted the audit [discrep-
The time after: winter 2010–summer 2012 ancy], (2) the costs and resources spent [frame], and (3)
According to the managers and the LPG, the ISO certifi- having brought their quality management system to an
cation process generated improvement of the manage- acceptable level. The ED management had generated
ment system; however, a direct impact on patient knowledge that enabled the ED to perform ongoing
treatment was hard to demonstrate [frame]. ISO 9001 system improvements on its own [frame]. However,
was considered as a managerial tool [frame]. When the some sort of external audit was considered necessary
revised management system was contrasted with the [concern]. Internal audits performed by the quality de-
situation before certification, it illustrated both positive partment in the hospital was in theory considered equal
practical implications and improved daily organizing of with external audits, but in practice the external audits
the ED [frame]. The ED management started talking dif- (e.g., by a certification body, NBHS, or the RHA) had
ferently about quality improvement, and used terms and stronger impact and triggered more managerial action
explanations that had originated from the standardization than internal audits [discrepancy]. Managers from the
and certification process [action]. They were proud of LPG changed their perspective on audits, from seeing
their achievement and gladly shared their material and ex- them as a way of controlling organizations to something
periences. The ISO standard and the additional useful for sustainable improvement [frame]. They started
Johannesen and Wiig Safety in Health (2017) 3:7 Page 10 of 14

asking for internal audits and acknowledged the possibil- ambiguities in relative stable institutional structures (the
ity of letting someone outside the department assess current internal control regulation and the ISO 9001
their systems and give feedback [action]. Nonconfor- certification). These ambiguities triggered sensemaking
mities were used as means for further improvement processes around continuity and change (the organiz-
[frame]. ing processes) towards internal control systems and
certification.
[F]or the last couple of years we have requested
audits, when there are things we are questioning. […] Situational triggers
It’s not so frightening anymore, and we see that it’s The first trigger relates to the nonconformities from the
very useful for us. That I think is a result of the countrywide ED supervision. For the ED management,
process. We are not so afraid of getting nonconformities, the nonconformities did not cause disruption, but rather
and see that these [nonconformities] are things that we verification of known challenges. What they now per-
can work on. (Informant V) ceived as different from earlier (a discrepancy), was the
increased focus upon these known challenges and turbu-
lence from the hospital’s top management. Treated
Discussion institutionally, such an increased focus can be explained
As a result of the countrywide supervision, the Norwe- by demands to follow up on nonconformities through
gian EDs were turned inside out in ways that made it institutional coercion [56, 57] or regulatory enforcement
obvious to ask whether it was safe to be a patient there. [58]. But in the sense that these onsite supervisions are
The turbulence did not lead to additional formal na- ad hoc initiatives, most often with years in between, they
tional inquiries or major policy changes that we have also have the potential to cause careless disruption or
seen from turbulence or health care crises in other surprises for organizations that can offer strong occa-
countries [54], but it was thoughtless disruption or tur- sions for sensemaking. Basically, it can be an interrup-
bulence that was a powerful occasion for organizational tion produced by new and unexpected circumstances
change [26]. The story of the adoption of an unfamiliar [24]. This seems to be true in this case study, where the
set of organizational requirements (ISO 9001), that had received nonconformities made known challenges
a quite circumstantial influence on the local ED manage- “visible” [59] for other parts of the organization and es-
ment, fits at first glance into the picture of sensemaking, pecially the top management, and so triggered further
where action and interpretation rather than evaluation actions for control and accountability.
on choice were present in the first face of the adoption The second trigger relates to the way in which external
process. A quick decision to become part of the pilot possibilities for assistance and support led to “quick” ac-
project was taken in the face of longstanding challenges tion and interpretation. The ED management’s uncer-
in the ED related to patient flow and management sys- tainty about proper solutions threatened their social
tems. These challenges had become a frame of reference identity. The external possibilities for support prompted
for the management, and different initiatives to resolve almost immediate action. Organizational uncertainty can
them had become discrepancies between what had been be seen as a form of ignorance or an inability to extrapo-
expected and the reality. It was not a surprise or a shock late current actions and therefore foresee future conse-
that prompted sensemaking, but ongoing discrepancies quences [24]. Such occasions lead people to construct
as circumstances great enough to expect people to ask processes of sensemaking to reduce that ignorance.
for what is going on, and what should they do next. This Plausibility and belief about current action, rather than
situation challenged the management’s social and shared accuracy about the future, are salient in such sensemak-
identity [24, 26, 31], as they were responsible for the ing processes. Early available sources and information
quality and safe running of the ED. Such an internal tur- that gave some sort of plausible directions for the ED,
bulent environment can in itself be treated as a trigger replaced uncertainty about the future, with more cer-
for managers’ engagement in sensemaking towards that tainty about the present, and as such made it possible to
specific challenge or threat [55]. The importance here is continue. The shared belief among the ED management
how the external environment triggered sensemaking prompt action, rather than change resistance, that often
processes that initiated the adoption, continuation, and are seen in organizational change when identity is
change in favor of ISO 9001 certification and additional challenged due to identity replacement, updating, or
standards. Four external triggers are identified. The first transformation [26, 55].
two external triggers (nonconformities and regional cer-
tification project participation) were situational-specific Institutional triggers
and present initially in the process. The last two triggers The third trigger relates to institutional structures in the
are institutional in nature [25], derived from perceived current internal control regulation. Adoption of internal
Johannesen and Wiig Safety in Health (2017) 3:7 Page 11 of 14

control system has shown to be a challenging task in self-reinforce a collaborative quality and safety culture
health care [60], and the ED did not have a system that [64]. These considerations on the auditor–auditee en-
was clearly built up around a fulfillment of these regula- counter may also underpin our present findings where
tory requirements. Finding solutions to operationalize there was a perceived discrepancy between the conduct
these requirements was inherent in the pilot project. of the first audit team (performing both the initial certi-
The LPG’s work on concretizing the requirements and fication audit and the first surveillance audit the first
developing additional requirements for EDs set in mo- year) and the conduct of the last surveillance audit team
tion important sensemaking processes about the internal the second year. The first team was perceived by the
control regulation. The internal control system is LPG to have real impact upon the standardization and
founded in a functional legislation [34, 61] with a wide improvement work in the ED. The conduct of the sec-
scope and possibilities for organizations to choose ond team was so different that it made the ED manage-
among a variety of tools for quality and safety work [62]. ment question the reliability of the certification process
It is a form of soft regulation that can be (too) diffuse and the meaning of renewing their certificate.
and therefore trigger organizations’ search for control A recent study [65] on stakeholder perspectives identi-
[28, 30]. It becomes a question of transparency and ac- fied four factors that seemed important to increase the
countability [59], not just in the eyes of external actors, likelihood of a successful implementation of accredit-
but for the organizations themselves. Because making ation: (1) the program is collaborative and valid and uses
things transparent is not just about documenting and relevant standards; (2) that accreditation is favorably re-
open the “curtains” for direct insight, it is also about ceived by health professionals; (3) that healthcare organi-
adopting new technologies that make organizational per- zations are capable of embracing accreditation; (4) and
formance visible [59]. The process of concretizing the that accreditation is appropriately aligned with other
requirements in the internal control regulation that the regulatory initiatives and supported by incentives. These
LPG performed was such a necessary visualization that findings highlight external regulatory structures and
gave meaning to their own system and processes [32]. intra-organizational factors that seem to be in line with
When analyzed from the perspective of Weber and findings on triggers and organizing perspectives related
Glynn’s [25] institutional trigger mechanism, we see that to certification in our study.
the stable institutional structure inherent in the regula-
tory system became ambiguous for the LPG and trigged Limitations
further sensemaking that made organizing possible. This single-case study is limited to meaning making pro-
These findings support other research arguing that a cesses within a single emergency department in a single
lack of competence on developing internal control sys- hospital in Norway. The small sample is a clear limita-
tems makes it difficult to adapt to the internal control tion of generalization from this study.
regulation in Norway [60].
The fourth trigger relates to the institution of ISO Conclusions
9001 certification. The present case study shows that the Certification and accreditation are widely used for qual-
ISO 9001 standard consisted of general and unfamiliar ity and safety in health care but also questioned in re-
concepts and systems that triggered the LPG to find spect to their assumed effects. This is a challenge for
ways to translate and contextualize these ambiguities, in policymakers since these regimes can have a circumstan-
their efforts to make sense of the standard. Seeing the tial impact upon different parts of the organization. The
ISO standard as a trigger relates to the same institu- present case study shows that the adoption of the ISO
tional triggering mechanism as for the third trigger. 9001 certification in an emergency department was not
What is different about the institution of ISO 9001 certi- led by a comprehensive decision-making process. It
fication is that it involves auditing process performed by shows that an exogenous disruption visualized long-
external auditors, and therefore integrates direct feed- standing organizational challenges that threatened the
back mechanisms that are interlinked with sensegiving managements shared identity. Again a search for mean-
perspectives [31, 63] or mechanisms on how institutions ing became prominent. The occasional possibility for
edit sensemaking [25]. Auditors control, negotiate, and help through an external standardization and certifica-
guide during their interactions with the organizations, tion project was a plausible solution that led to immedi-
and those tasks give auditors room for different interpre- ate action, and reduced uncertainty. Further, the case
tations and conducts of their same auditing role. Con- study shows that the relative stable institutional require-
cerns about interaction are important, because research ments that are inherent in the internal control regula-
on accreditation shows that when health professionals tion and the certification standard were unfamiliar and
are given the opportunity to participate in assessment ambiguous and therefore triggered local sensemaking
contexts that are collaborative and supportive, it can processes for a contextualization of these regulations
Johannesen and Wiig Safety in Health (2017) 3:7 Page 12 of 14

and standards, which made the continuation and change Funding


possible. It also led to the acknowledgment of external This article is part of a PhD project funded by the Ministry of Education and
Research in Norway.
assessments or audits in general as useful for improve-
ment work. Availability of data and materials
When considering implications for further theory de- The data generated and analyzed during this study are not publicly available
due to concerns about confidentiality regarding a small sample size and the
velopment, we see that the institutional trigger mechan- sensitive nature of the interviews. Instead, quotations and analytical categories
ism in Weber and Glyns’ [25] framework contributes to are included in the text. We are happy to discuss the findings or the analysis if
explaining the occasion for sensemaking. There is a need any questions should arise.
for more research that can refine this institutional mech-
Authors’ contributions
anism (in addition to institutional constraints) and in- DTSJ was responsible for the conception and design of the study and
form explanations of why some regulatory institutions undertook acquisition of data as well as analysis and interpretation of data.
give rise to (trigger) adoption of different modern man- SW was consulted during the analysis, and interpretation process. DTSJ led
the drafting of the manuscript. DTSJ and SW were both involved in critically
agement tools (e.g., certification or accreditation). These revising the manuscript for important intellectual content and both read and
considerations are important, because when organiza- approved the final manuscript.
tions adopt new management tools, they seldom
Ethics approval and consent to participate
abandon others. This can lead to even more complex The research was performed with the ethical approval of the Norwegian Social
health care. Science Data Services (December 16, 2011, Ref. 27543). A clearance for staff
interviews was obtained from the hospital prior to data collection. Informants first
got a written invitation to participate at its inception and then a written and oral
invitation prior to the commencement of recording. The invitation explained that
Endnotes the interview was part of a research project, that the results would be used
1
Governance in this perspective refers more to the anonymously for analysis and publication, and that participation was voluntary
and could be terminated at any time. All informants provided oral consent.
neoliberal approaches inspired by rational choice theor-
ies and governance as networks within the institutional Consent for publication
tradition, than to a decentered theory of governance Our manuscript does not contain any individually identifiable person’s data.
underpinned by postfoundational philosophy and demo- All informants have got the opportunity to read and respond to a late draft
of the manuscript, including quotes, before submission.
cratic stands [67].
2
Norwegian Accreditation (NA) is the Norwegian body Competing interests
for accreditation of laboratories and sampling organiza- The authors declare that they have no competing interests.
tions, certification bodies, inspection bodies, and envir-
onmental verifiers. NA represents Norway on three Publisher’s Note
European and international bodies—the European co- Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
operation for Accreditation, the International Laboratory
Accreditation Cooperation and the International Ac- Author details
1
creditation Forum. NA is also the Norwegian monitoring Department of Media, Culture and Social Sciences, University of Stavanger,
4036 Stavanger, Norway. 2Department of Health and Nursing Science,
body for Good Laboratory Practice (GLP) inspections, University of Agder, 4604 Kristiansand, Norway. 3Department of Health
according to OECD’s GLP principles (http://www.akkre- Studies, University of Stavanger, 4036 Stavanger, Norway.
ditert.no/en/om-oss/, accessed 12. February 2014).
3 Received: 16 May 2017 Accepted: 4 July 2017
Norwegian Accreditation establishes different sector
committees, often broadly represented, when the aim is
to establish a new standard on a new domain or sector. References
4 1. Storting: Case 2: Recommendation from the healthcare committee about
Surveillance audit is a yearly onsite audit so that the the representative proposals from members of parliament Erna Solberg,
certification body can maintain confidence that the certi- Inge Lønning and Sonja Irene Sjøli about better quality in hospital [In
fied management system continues to fulfill require- Norwegian: Innstilling fra helse- og omsorgskomiteen om
representantforslag fra stortingsrepresentantene Erna Solberg, Inge Lønning
ments between (re-)certification and re-certification [21]. og Sonja Irene Sjøli om bedre kvalitet i sykehus] (Innst. S. nr. 204 (2008–
2009), jf. Dokument nr. 8:29 (2008–2009)). Minute from meeting Thursday
14. May 2009. 10.00 A.M. 2009: 3004–3009.
Abbreviations 2. Norwegian Ministry of Health and Care Services. Meld.St. 10 (2012–2013)
ED: Emergency department; ISO: International Organization for Report to the storting (white paper). High Quality - Safe Services. Quality
Standardization; LPG: Local project group; NBHS: Norwegian Board of Health and Patient safety in the Health and Care Services. 2012.
Supervision; RHA: Regional Health Authorities; RPG: Regional project group 3. Norwegian Ministry of Health and Care Services. Meld.St. 11 (2015–2016) Report
to the storting (white paper). Nasjonal helse- og sykehusplan (2016–2019). 2015.
4. Greenfield D, Braithwaite J. Developing the evidence base for accreditation
Acknowledgements of healthcare organisations: a call for transparency and innovation. Qual
The authors would like to thank the hospital for the access to the field and Safety Health Care. 2009;18(3):162–3.
also thanks so much to all informants for taking part in the study and for 5. Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review
giving feedback on the narratives to the authors. We would like to thank the of hospital accreditation: the challenges of measuring complex intervention
Ministry of Education and Research for the funding of the PhD project. effects. BMC Health Serv Res. 2015;15(1):280.
Johannesen and Wiig Safety in Health (2017) 3:7 Page 13 of 14

6. Grepperud S. Is the hospital decision to seek accreditation an effective one? 35. Regulations of 20. December 2002 realting to internal control in the social
Int J Health Plann Manag. 2015;30(1):E56–68. and health services [In Norwegian: FOR 2002-12-20 nr 1731: Forskrift om
7. Flodgren G, Gonçalves-Bradley DC, Pomey M-P. External inspection of internkontroll i sosial- og helsetjenesten]; 2002
compliance with standards for improved healthcare outcomes. Cochrane 36. Schaefer C, Wiig S. Strategy and practise of external inspection in healthcare
Database System Rev. 2016;12:CD008992. services—a Norwegian comparative case study. Safety in Health. 2017;3(1):3.
8. Haute Autorité de Santé: Literature review on the impact of hospital 37. Eastern Norway Regional Health Authorities: Annual report from the Eastern
accreditation. In. Paris: MATRIX Knowledge group; 2010. Norway RHA to the Ministry of Health and Care Services [In Norwegian: Årlig
9. Greenfield D, Braithwaite J. Health sector accreditation research: a melding fra Helse Øst RHF til Helse- og omsorgsdepartementet]. Hamar; 2005.
systematic review. Int J Qual Health Care. 2008;20(3):172–83. 38. Arntzen E, Mikkelsen B. Internkontroll, sertifisering og akkreditering.
10. Hinchcliff R, Greenfield D, Moldovan M, Westbrook JI, Pawsey M, Mumford Tisdsskrift Nor Lægeforen. 2005;6(125):767–9.
V, Braithwaite J. Narrative synthesis of health service accreditation literature. 39. Yin RK. Case study research: design and methods. 5th ed. Los Angeles:
BMJ Quality Safety. 2012;21(12):979–91. Sage; 2014.
11. Sunol R, Vallejo P, Thompson A, Lombarts MJMH, Shaw CD, Klazinga N. 40. Rhodes C, Brown AD. Narrative, organizations and research. Int J Manag Rev.
Impact of quality strategies on hospital outputs. Qual Safety Health Care. 2005;7(3):167–88.
2009;18 Suppl 1:i62–8. 41. Langley A. Strategies for theorising from process data. Acad Manag Rev.
12. Shaw C, Groene O, Mora N, Sunol R. Accreditation and ISO certification: do 1999;24(4):691–710.
they explain differences in quality management in European hospitals? Int J 42. Czarniawska B. Narratives in social science research. London: Sage
Qual Health Care. 2010;22(6):445–51. Publications; 2004.
13. Shaw CD, Groene O, Botje D, Sunol R, Kutryba B, Klazinga N, Bruneau C, 43. Brown AD, Stacey P, Nandhakumar J. Making sense of sensemaking
Hammer A, Wang A, Arah OA, et al. The effect of certification and narratives. Human Relations. 2008;61(8):1035–62.
accreditation on quality management in 4 clinical services in 73 European 44. Currie G, Brown AD. A narratological approach to understanding processes
hospitals. Int J Qual Health Care. 2014;26 suppl 1:100–7. of organizing in a UK hospital. Human Relations. 2003;56(5):563–86.
14. Falstie-Jensen AM, Larsson H, Hollnagel E, Nørgaard M, Svendsen MLO, Johnsen 45. Boje DM. Narrative methods for organizational and communication
SP. Compliance with hospital accreditation and patient mortality: a Danish research. London: Sage; 2001.
nationwide population-based study. Int J Qual Health Care. 2015;27(3):165–74. 46. Brown AD, Gabriel Y, Gherardi S. Storytelling and change: an unfolding
15. Devkaran S, O’Farrell PN. The impact of hospital accreditation on quality measures: story. Organization. 2009;16(3):323–33.
an interrupted time series analysis. BMC Health Serv Res. 2015;15(1):137. 47. Gubrium JF, Holstein JA, Marvasti AB, McKinney KD. The SAGE handbook of
16. Ehlers LH, Simonsen KB, Jensen MB, Rasmussen GS, Olesen AV. interview research: the complexity of the craft. 2nd ed. Thousand Oaks:
Unannounced versus announced hospital surveys: a nationwide cluster- Sage; 2012.
randomized controlled trial. Int J Qual Health Care. 2017;1:6. 48. Steyer V, Laroche H, Jonczyk C. The Crisis that did not Happen: a study of
17. Shaw CD, Braithwaite J, Moldovan M, Nicklin W, Grgic I, Fortune T, Whittaker Multi-Level Sensemaking. Paper presented at the Second International
S. Profiling health-care accreditation organizations: an international survey. Symposium on Process Organization Studies. Rhodes: International
Int J Qual Health Care. 2013;25(3):222–31. Symposium on Process Organization Studies; 2010.
18. Bromley P, Powell WW. From smoke and mirrors to walking the talk: 49. Weick KE. Making sense of the organization. Oxford: Blackwell; 2001.
decoupling in the contemporary world. Acad Manag Ann. 2012;6(1): 50. Polkinghorne DE: narrative configuration in qualitative analysis. In: Life
483–530. History and Narrative. edn. Edited by Hatch JA, Wisniewski R: Taylor and
19. Shaw C. External assessment of health care. BMJ. 2001;322(7290):851–4. Francis; 1995.
20. Bohigas L, Heaton C. Methods for external evaluation of health care 51. Norwegian board of Health Supervision. “While we are waiting….”—do
institutions. Int J Qual Health Care. 2000;12(3):231–8. patients receive adequate treatment in accident and emergency units?
21. ISO. Conformity assessment—requirements for bodies providing audits and Summary of countrywide supervision in 2007 of accident and emergency
certification of management systems (ISO/IEC 17021:2011). 2011. units in specialized health services—are services of adequate quality and do
22. ISO. Quality management systems- requirements (ISO 9001:2008). 2008. they meet legislative requirements? In: Report from the Norwegian Board of
23. European Committee for Standardization. CEN/TS 15224:2005 - Quality Health Supervision 2/2008. 2008.
Management in health services, Guidelines for the use of NS-EN ISO 9001: 52. South-East Norway Regional Health Authority, Norwegian Accreditation.
2000. 2005. Project Proposel - Accreditation in Emergency Departments “… for good
24. Weick KE. Sensemaking in organizations. Thousand Oaks: Sage; 1995. and equal health services” [In Norwegian: Prosjektplan - Akkreditering i
25. Weber K, Glynn MA. Making sense with institutions: context, thought and akuttmottak.” …for gode og likeverdige helsetjenester.”]. Oslo; 2008.
action in Karl Weick’s theory. Organ Stud. 2006;27(11):1639–60. 53. Norwegian Accreditation. Report from the Norwegian Accreditation Sector
26. Maitlis S, Sonenshein S. Sensemaking in crisis and change: inspiration and committee P-14 Emergency Departments [In Norwegian: Rapport fra Norsk
insights from Weick (1988). J Manag Stud. 2010;47(3):551–80. Akkrediterings sektorkomite P-14 akuttmottak]. 2011.
27. Powell WW, Colyvas JA. Microfoundations of institutional theory. In: 54. Hindle D, Braithwaite J, Travaglia J, Iedema R. Patient Safety: a comparative
Greenwood R, Oliver C, Suddaby R, Sahlin K, editors. The Sage Handbook of analysis of eight Inquiries in six countries. Sydney: Centre for Clinical
Organizational Institutionalism. Volume 1. London: SAGE Publication; 2008. Governance Research, Faculty of Medicine, University of New South
28. Djelic M-L, Sahlin-Andersson K. Introduction: a world of governance: the rise Wales; 2006.
of transnational regulation. In: Djelic M-L, Sahlin-Andersson K, editors. 55. Maitlis S, ChristiansoN M. Sensemaking in Organizations: Taking stock and
Transnational governance: institutional dynamics of regulation. Cambridge: moving forward. Acad Manag Ann. 2014;8(1):57–125.
Cambridge University Press; 2006. p. 1–28. 56. DiMaggio PJ, Powell WW. The iron cage revisited: institutional isomorphism
29. Black J. Constructing and contesting legitimacy and accountability in and collective rationality in organizational fields. Am Sociol Rev. 1983;48(2):
polycentric regulatory regimes. Reg Govern. 2008;2(2):137–64. 147–60.
30. Sahlin K, Wedlin L. Circulating ideas: imitation, translation and editing. In: 57. Scott WR. Institutions and organizations: ideas and interests. Thousand Oaks:
Greenwood R, Oliver C, Suddaby R, Sahlin K, editors. The SAGE Handbook of Sage Publications; 2008.
Organizational Institutionalism. London: Sage; 2008. p. 218–42. 58. Gunningham N. Enforcement and compliance strategies. In: Baldwin R, Cave
31. Weick KE, Sutcliffe KM, Obstfeld D. Organizing and the process of M, Lodge M, editors. The Oxford handbook of regulation. Oxford: Oxford
sensemaking. Organ Sci. 2005;16(4):409–21. University Press; 2010. p. 120–45.
32. Weick KE. Quality improvement. A sensemaking perspective. In: Cole RE, 59. Blomgren M, Sahlin K. Quests for transparency: signs of a new institutional
Scott WR, editors. The quality movement & organization theory. Thousand era in the health care field. In: Christensen T, Lægreid P, editors.
Oaks: Sage; 2000. p. 155–72. Transcending new public management: the transformation of public sector
33. Mills JH. Making sense of organizational change. New York: Routledge; 2003. reforms. Aldershot: Ashgate; 2007. p. 155–77.
34. Coglianese C, Mendelson E. Meta-regulation and self-regulation. In: Baldwin 60. Wiig S, Storm M, Aase K, Gjestsen M, Solheim M, Harthug S, Robert G, Fulop N.
R, Cave M, Lodge M, editors. The Oxford handbook of regulation. Oxford: Investigating the use of patient involvement and patient experience in quality
Oxford University Press; 2010. p. 146–68. improvement in Norway: rhetoric or reality? BMC Health Serv Res. 2013;13:206.
Johannesen and Wiig Safety in Health (2017) 3:7 Page 14 of 14

61. Ayres I, Braithwaite J. Responsive regulation: transcending the deregulation


debate. New York: Oxford University Press; 1992.
62. Gilad S. It runs in the family: meta-regulation and its siblings. Reg Govern.
2010;4(4):485–506.
63. Maitlis S, Lawrence TB. Triggers and enablers of sensegiving in
organizations. Acad Manag J. 2007;50(1):57–84.
64. Greenfield D, Pawsey M, Braithwaite J. What motivates professionals to
engage in the accreditation of healthcare organizations? Int J Qual Health
Care. 2011;23(1):8–14.
65. Hinchcliff R, Greenfield D, Westbrook JI, Pawsey M, Mumford V, Braithwaite
J. Stakeholder perspectives on implementing accreditation programs: a
qualitative study of enabling factors. BMC Health Serv Res. 2013;13(1):1–9.
66. Jennings PD, Greenwood R. 6b constructing the iron cage: institutional
theory and enactment. In: Westwood RI, Clegg S, editors. Debating
organization: point-counterpoint in organization studies. Malden: Blackwell
Publishing; 2003. p. 195–207.
67. Bevir M. A theory of governance. London: University of California Press; 2013.

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• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research

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