Integrating Quality Improvement: A Qualitative Study of Leadership Approaches in Healthcare Services in Norwegian Municipalities.

Background/Objective: Healthcare services must provide high-quality patient care and continuously work to improve the quality of the organization. Continuous quality improvement (QI) involves systematic and ongoing enhancements of individual treatments as well as large organizational structures. To facilitate QI, suitable organizational structures are required. This study aims to describe and explore how administrative leaders organize for continuous QI in a Norwegian municipal setting. Methods: This qualitative study examines how administrative leaders organize for QI in Norwegian municipalities by conducting semi-structured interviews with leaders and quality advisors (N = 19) in three Norwegian municipalities. The data were analyzed inductively by reflexive thematic text analysis and the software NVIVO 14. Results: The municipalities used three main approaches to organize QI, aimed at integrating QI into their governing structures. The vertical approach aligned QI formalities with hierarchical structures. The horizontal approach created tailored structures for operationalizing and implementing QI. In the mediating approach, leaders actively and continuously worked vertically, horizontally, and across levels and units to reconcile differences, cooperate, communicate, and monitor activities, securing trust and commitment toward QI. Their responsibilities were extensive, supported by delegating responsibility to lower-level leaders and quality advisors, the latter with key roles in QI. QI functioned as a planned activity and continuous process. Trust and commitment were essential across approaches. Leaders' continuous mediating activities helped address the tensions between autonomy and commitment, specialized or integrated assistance, and balancing change, trust and control. These were critical to QI's success. Conclusion: The different approaches to organizing QI facilitated the implementation of QI in various situations and alleviated tensions regarding the autonomous units' commitment to decisions and the integration or specialization of QI. The various approaches to QI, integrated with different bureaucratic models, created complex processes of layering new elements into existing structural forms, thereby modernizing municipal structures.