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01.12.2018 | Research article | Ausgabe 1/2018 Open Access

BMC Health Services Research 1/2018

Using regulatory enforcement theory to explain compliance with quality and patient safety regulations: the case of internal audits

BMC Health Services Research > Ausgabe 1/2018
Ulrike Weske, Paul Boselie, Elizabeth L. J. van Rensen, Margriet M. E. Schneider
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Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12913-018-2865-8) contains supplementary material, which is available to authorized users.



Implementing an accredited quality and patient safety management system is inevitable for hospitals. Even in the case of an obligatory rule system, different approaches to implement such a system can be used: coercive (based on monitoring and threats of punishment) and catalytic (based on dialogue and suggestion). This study takes these different approaches as a starting point to explore whether and how implementation actions are linked to compliance. By doing so, this study aims to contribute to the knowledge on how to increase compliance with obligatory rules and regulations.


The internal audit system (the ‘tracer system’) of a large Dutch academic hospital is used as a case to investigate different implementation approaches and their effect on compliance. This case allowed us to use a multi-actor and multi-method approach for data collection. Internal audits (N = 16) were observed, audit reports were analyzed, and semi-structured interviews were conducted with both the internal auditors (N = 23) and the ward leaders (N = 14) responsible for compliance. Framework analysis was used to analyze the data.


Although all auditors use catalytic enforcement actions, these do not lead to (intended) compliance of all ward leaders. Rather, the catalytic actions contribute to (intended) compliance of ward leaders that are motivated, whereas they do not for the ward leaders that are not motivated. For the motivated ward leaders, catalytic enforcement actions contribute to (intended) compliance by increasing ward leaders’ knowledge of the rules and how to comply with them.


Our findings suggest that the effectiveness of implementation actions depends not only on the actions themselves, but also on the pre-existing motivation to comply. These findings imply that there is not one ‘best’ approach to the implementation of obligatory rules. Rather, the most effective approach depends on the willingness to comply with rules and regulations.
Additional file 1: Overview of Auditors. (DOCX 14 kb)
Additional file 2: Interview Guides. (DOCX 19 kb)
Additional file 3: Data sources for auditor enforcement style. (DOCX 18 kb)
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