From Adoption to Routinization: A Theory-Informed Qualitative Case Study of Quality-Management Implementation in a Chinese County Hospital

Background: County hospitals play a central role in delivering health services in China; however, the introduction of quality-management tools does not guarantee the sustained use of these tools in these institutions. Therefore, this study examined how a county hospital in China adopted total quality management (TQM)-oriented practices and whether these practices became embedded in routine operations or remained unimplemented. Methods: A theory-informed, qualitative single-case study was conducted at a public general hospital in Zhejiang, China. The data comprised 32 semi-structured interviews, institutional documents, and supplementary observations. Participants included 10 administrators or quality-management leaders, 15 frontline staff members, and 7 patients or caregivers. Two trained research assistants independently coded the qualitative corpus; discrepancies were resolved through three consensus meetings and adjudication by the authors. Framework analysis examined adoption, routinization, and the tension between compliance and learning. Administrative indicators were critically appraised as contextual evidence. Results: External accountability and leadership supported the adoption of quality structures; however, inspection-driven activities did not consistently translate into everyday learning. Some accounts indicated that continuous quality improvement (CQI) tools supported incident analysis and process redesign, while others described an emphasis on documentation. Training and drills helped clarify emergency roles, whereas hierarchical structures and departmental silos constrained routine collaboration. Patient and caregiver interviews provided illustrative accounts of improved communication and navigation, alongside concerns regarding participation in decision-making. Administrative trends were broadly consistent with these accounts; however, incomplete measurement information precluded causal attribution. Conclusion: Substantial adoption coexisted with uneven routinization. Local ownership, data interpretation, practical rehearsal, and continued feedback emerged as conditions relevant to sustained use. County-hospital quality management should assess how tools are used and followed up, alongside whether they have been introduced. Patient participation requires further investigation beyond satisfaction measures and the small patient/caregiver subsample.