From exception to insight: a phenomenological study of quality managers' perspectives on the individual appeals in the National Healthcare Quality Program

National quality indicators play a crucial role in monitoring hospital performance and fostering accountability. However, standardized indicators often fail to capture the intricate realities of clinical practice. To mitigate this limitation, Israel's National Program for Quality Indicators for general, geriatric, and psychiatric hospitals has implemented an individual appeals process, enabling hospitals to request case-based exclusions from indicator calculations when performance deviations arise from factors beyond their control. After three years of this initiative, our goal is to investigate the experiences of hospital Quality Managers (QMs) with the individual appeals track, aiming to inform enhancements to the national quality indicators program.

A qualitative, phenomenological study was conducted using semi-structured interviews with ten QMs from general, geriatric, and psychiatric hospitals. Interviews were analyzed using thematic, textual, and content analysis.

Three core themes emerged: (1) Knowledge and familiarity gaps - most QMs relied on experiential learning rather than formal training or Ministry guidelines; (2) Communication gaps - strong collaboration existed within hospitals and with supervising nurses, but limited dialogue and feedback occurred with higher Ministry levels or across institutions; (3) Recognition gaps - QMs perceived acceptance of appeals as professional validation, while rejections often evoked frustration and a sense of underappreciating.

QMs' experiences highlight systemic gaps in training, communication, and recognition that influence the perceived legitimacy and effectiveness of the individual appeals track. Strengthening structured onboarding, establishing transparent two-way communication, and embedding formal recognition mechanisms could enhance motivation, professional confidence, and the program's credibility.

Institutionalizing the appeals process as a formal policy tool supported by standardized training, inter-hospital learning forums, and routine feedback loops can transform it from a technical exception mechanism into a strategic platform for continuous quality improvement and policy learning within Israel's healthcare system.