Beyond Blame: cultural barriers to medical reporting

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the ‘culture of blame’. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an ‘inevitable’ and potentially unmanageable feature of medical work and incident reporting was therefore ‘pointless’. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous ‘culture of blame’ and instead address the ‘culture of medicine’, especially as it relates to the collegial and professional control of quality

New development:Clinicians in management—past, present, future?

There is growing evidence that greater involvement of healthcare professionals in the governance ofcare organizations is positively associated with increased care quality and safety. Recent researchfurther suggests that a critical mass of doctors can help senior management in delivering on theirgovernance responsibilities. Prompted by a recent article inPublic Money & ManagementbyKirkpatrick et al. (2023), this article looks at the past, present and future of clinical involvement inhealthcare management. As well as locating this growing body of research in wider social sciencedebates, it outlines a number of potential lines for future enqu

The struggles for (and of) network management: an ethnographic study of non-dominant policy actors in the English healthcare system

The coordinating skills of network management are well-documented, but there is little understanding of how network management roles are acquired and sustained. This article reports on a two-year ethnographic study that investigated the introduction of a regional healthcare network in England. It describes the strategies used by non-dominant actors to acquire and sustain network management roles in the face of opposition from more powerful actors. These strategies complement existing theory on network management and offer new theoretical understanding regarding the social position of network managers

From boundary object to boundary subject; the role of the patient in coordination across complex systems of care during hospital discharge

From boundary object to boundary subject; the role of 1 the patient in coordination across complex systems of 2 care during hospital discharge 3 4 Abstract 5 Advocates for patient involvement argue that seeking the active contribution of 6 patients and families in the coordination of care can help mitigate system 7 complexity, and lead to improvements in quality. However, sociological and 8 organisational research has identified barriers to involving patients in care 9 planning, not least the power of, and boundaries between, multiple professional 10 groups. This study draws on literature from Science and Technology Studies (STS) 11 to explore the patients' role in coordinating care across professional-practice 12 boundaries in complex care systems. Findings are drawn from a two-year 13 ethnographic study (including 69 qualitative interviews) of hospital discharge 14 following hip-fracture care, and describe the changing role of the patient as they 15 move out of hospital into community settings. Findings describe how 'the patient' 16 plays a relatively passive role as boundary object while recovering from surgery 17 within hospital, where inter-professional coordination was prescribed by 18 evidence-based guidelines, leaving little space for patient voice. As discharge 19 planning begins, patient involvement is both encouraged and contested by 20 different professional groups, with varying commitment to include patient 21 subjectivities in care. As patients move into home and community settings, they, 2

Crossing boundaries: Establishing a framework for researching quality and safety in care transitions

Background Despite the breadth and diversity of research and policies on care transitions, research studies often report similar components that affect the quality and safety of care, including communication across professional groups and care settings, transfer of information, coordination of resources or training of healthcare personnel. In this article, we aim to deepen our understanding of care transitions by proposing a heuristic research framework that takes into account the components and factors influencing the quality and safety of care transitions in diverse settings. Methodology Using a pragmatic qualitative narrative meta-synthesis of empirically grounded research studies (N = 13) involving 31 researchers from seven countries (Australia, Canada, Denmark, Germany, the Netherlands, Norway and the UK), we conducted a thematic analysis to identify the components analysed in the included studies. We then used these components to create a framework for researching care transitions. Results Our narrative synthesis found that the quality and safety of care transitions are influenced by a range of patient-centred, communicative, collaborative, cultural, competency-based, accountability-based and spatial components. These components are encompassed within a broader set of dimensions that require careful consideration: (1) the conceptualising of the care transition notion, (2) the methodology for researching care transitions, (3) the role of patients and carers in care transitions, (4) the complexity surrounding care transitions, (5) the boundaries intertwined in care transitions and (6) care transition improvement interventions. These six dimensions constitute an analytical framework for planning and conducting research on care transitions in diverse settings. Conclusion The proposed six-dimensional framework for researching quality and safety in care transitions offers a roadmap for future practice and policy interventions and provides a starting point for planning and designing future research.publishedVersio

Co-creation of social innovations and new professional institutions: diffusion of therapeutic patient education (TPE) for diabetes in Austria

Patient-centred education in diabetes is a radical social innovation that alters the social and medical relationship between patients and medics. This paper discusses the ways in which institutional work conducted by national and international professional associations has shaped development and diffusion of this social innovation within the Austrian health system. The case study contributes to our understanding of social innovation and institutional change in two respects. First, it highlights the need for purposive institutional work in order to disrupt pre-existing institutions and, thereby, ensure the development and diffusion of a social innovation amongst a community of medical practitioners. Second, the case shows the overtly political work, policing, and educating work that professional associations undertook with funding bodies and key policy-makers in order to develop a national programme for diabetes education

Between empowerment and self-discipline: governing patients' conduct through technological self-care

Recent health policy renders patients increasingly responsible for managing their health via digital technology such as health apps and online patient platforms. This paper discusses underlying tensions between empowerment and self-discipline embodied in discourses of technological self-care. It presents findings from documentary analysis and interviews with key players in the English digital health context including policy makers, health designers and patient organisations. We show how discourses ascribe to patients an enterprising identity, which is inculcated with economic interests and engenders self-discipline. However, this reading does not capture all implications of technological self-care. A governmentality lens also shows that technological self-care opens up the potential for a de-centring of medical knowledge and its subsequent communalization. The paper contributes to Foucauldian healthcare scholarship by showing how technology could engender agential actions that operate at the margins of an enterprising discourse

Hospital discharge of the elderly: an observational case study of functions, variability and performance-shaping factors

Background: Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin). Methods: The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge. Results: We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives). Conclusions: The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions

Doctors' thinking about the system as a threat to patient safety

‘Systems thinking’ is an important feature of the emerging ‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages clinicians to look past individualerror to recognise the latent factors that threaten safety. This paper investigates whether current medical thinking is commensurate with the idea of ‘systems thinking’ together with its implications for policy. The findings are based on qualitative semistructured interviews with specialist physicians working within one NHS District General Hospital in the English Midlands. It is shown that, rather then favouring a 'person-centred’ perspective, doctors readily identify ‘the system’ as a threat to patient safety. This is not necessarily a reflection of the prevailing safety discourse or knowledge of policy, but reflects a tacit understanding of how services are (dis)organised. This line of thinking serves to mitigate individual wrong-doing andprotect professional credibility by encouraging doctors to accept and accommodate the shortcomings of the system, rather than participate in new forms of organisational learning

Mapping the public sector diaspora: towards a model of inter-sectoral cultural hybridity using evidence from the English healthcare reforms

Public service reforms increasingly blur the boundaries between public and private sectors, involving hybrid modes of service organization. With growing numbers of public services being transferred to private or mutual ownership, the article interprets reform as a public sector diaspora. Drawing upon the diaspora studies literature, the article proposes a model of hybridization that centres on the possibilities for cultural dislocation, adaptation, and hybridity. Focusing on reforms within the English National Health Service, the article presents an ethnographic study of the transfer or diaspora of doctors, nurses, clinical practitioners, and healthcare assistants from a public hospital to a private healthcare provider, exploring their experiences of migration, resettlement, and cultural hybridity. The model addresses a conceptual gap within the public policy and management literature by elaborating the antecedents, processes, and forms of cultural hybridization