When small bandages fail:the field-level repair of severe and protracted institutional breaches

We present the first elaboration of the field-level institutional repair work enacted by government inquiry reports into severe and protracted breaches of the institution of medicine in the English National Health Service. Our examination of the interplay between the rhetorical argumentation strategies communicated, the modes and types of institutional work conveyed, and the institutional pillars targeted for repair enhances understanding of field-level institutional repair work in three ways. First, our analysis of forensic and deliberative rhetoric reveals how these communicate aligned ethos, logos, and pathos appeals in a tactical buttressing manner that simultaneously harnesses maintenance, adapted creative and disruptive modes of institutional work. Ensuing repair work is primarily directed to the regulatory and normative pillars of the breached institution, though their consequential effects seek to realign the cultural-cognitive pillar. Second, adapted creative and disruptive modes interact to generate elaborative and/or eliminative institutional work. This fosters a dynamic form of institutional maintenance, wherein the breached institution evolves in order to endure within the changing terrain of the field. Finally, our elaboration of field-level institutional repair work offers insight into the relative plasticity of the institution of medicine, and contributes to understanding of the dark side of institutional work

Systematic literature review of burden of illness in chronic inflammatory demyelinating polyneuropathy (CIDP)

Altres ajuts: CSL Behring GmbHBackground: Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare neurological disorder characterised by muscle weakness and impaired sensory function. The present study provides a comprehensive literature review of the burden of illness of CIDP. Methods: Systematic literature search of PubMed, Embase, and key conferences in May 2019. Search terms identified studies on the epidemiology, humanistic burden, current treatment, and economic burden of CIDP published since 2009 in English. Results: Forty-five full texts and nineteen conference proceedings were identified on the epidemiology (n = 9), humanistic burden (n = 7), current treatment (n = 40), and economic burden (n = 8) of CIDP. Epidemiological studies showed incidence and prevalence of 0.2-1.6 and 0.8-8.9 per 100,000, respectively, depending on geography and diagnostic criteria. Humanistic burden studies revealed that patients experienced physical and psychosocial burden, including impaired physical function, pain and depression. Publications on current treatments reported on six main types of therapy: intravenous immunoglobulins, subcutaneous immunoglobulins, corticosteroids, plasma exchange, immunosuppressants, and immunomodulators. Treatments may be burdensome, due to adverse events and reduced independence caused by treatment administration setting. In Germany, UK, France, and the US, CIDP economic burden was driven by direct costs of treatment and hospitalisation. CIDP was associated with indirect costs driven by impaired productivity. Conclusions: This first systematic review of CIDP burden of illness demonstrates the high physical and psychosocial burden of this rare disease. Future research is required to fully characterise the burden of CIDP, and to understand how appropriate treatment can mitigate burden for patients and healthcare systems

A multilevel neo-institutional analysis of infection prevention and control in English hospitals: coerced safety culture change?

Despite committed policy, regulative and professional efforts on healthcare safety, little is known about how such macro-interventions permeate organisations and shape culture over time. Informed by neo-institutional theory, we examined how inter-organisational influences shaped safety practices and inter-subjective meanings following efforts for coerced culture change. We traced macro-influences from 2000 to 2015 in infection prevention and control (IPC). Safety perceptions and meanings were inductively analysed from 130 in-depth qualitative interviews with senior- and middle-level managers from 30 English hospitals. A total of 869 institutional interventions were identified; 69% had a regulative component. In this context of forced implementation of safety practices, staff experienced inherent tensions concerning the scope of safety, their ability to be open and prioritisation of external mandates over local need. These tensions stemmed from conflicts among three co-existing institutional logics prevalent in the NHS. In response to requests for change, staff flexibly drew from a repertoire of cognitive, material and symbolic resources within and outside their organisations. They crafted 'strategies of action', guided by a situated assessment of first-hand practice experiences complementing collective evaluations of interventions such as 'pragmatic', 'sensible' and also 'legitimate'. Macro-institutional forces exerted influence either directly on individuals or indirectly by enriching the organisational cultural repertoire

Recovering the Divide: A Review of Strategy and Tactics in Business and Management

With origins in military history, strategy and tactics is a frequently used conceptual couplet in the business and management literature. This paper reviews how strategy and tactics are portrayed, identifying a dominant ‘pragmatic’ account of strategy as an expression of formal, planned ends achieved through the subordinate means of tactics. Pragmatic distinctions give rise to a range of well-known problems, in particular in strategy implementation stages. We suggest that some of these problems may be avoided when the strategy–tactics relationship is conceived differently. We elaborate two alternative distinctions: a sociological framing of tactics as mechanisms of resistance to formal, controlling strategies; and a processual perspective, which sidesteps fixed distinctions between tactics and strategy, giving rise to more fluid interrelations between both modes. Based on a review of the business and management literature, we identify key examples of each trope and conclude by drawing insights for each account on the basis of these wider discussions

A realist analysis of hospital patient safety in Wales:Applied learning for alternative contexts from a multisite case study

Background: Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms. Objectives: This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes. Design: We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+ patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction. Setting: Welsh Government and NHS Wales. Participants: Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety. Main outcome measures: Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+ patient safety programme in Welsh NHS hospitals. Results: An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme. Conclusions: Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Strategizing:talk in action

This paper examines the discursive enactment of strategizing in a complex, multi-organizational, public sector strategic arena, sculpted by structural and cultural constraints, and the power games inherent to hegemonic contestation from the boardroom to the boundary of the organizational field. It combines Archerian critical realism with Fairclough’s dialectical-relational approach to critical discourse analysis to develop a more holistic understanding of the performative relationship between talk and action in strategizing. In doing so, it defines the semiotic scaffolding of the situational logic that manifests within the strategic arena, to reveal the role of discourse in the construction and mobilization of ensuing agency, and thus how stakeholders’ expectations are addressed—or discounted—in strategy formation

'They have the power because they've got the knife':Examining leadership in an inter-professional healthcare arena

This development paper presents a critical discourse analysis of leadership as a dialectical relational construct. In so doing, we draw upon a comparative-intensive case study of the implementation of the 1000 Lives+ national patient safety programme in NHS Wales, and direct empirical attention on the implementation and operationalisation of the World Health Organization’s Surgical Safety Checklist in the interprofessional arena of the operating theatre