Moral judgements as organizational accomplishments : insights from a focused ethnography in the English healthcare sector

In this chapter, we aim to deepen our understanding of judgments in organizations. Whilst previous studies have underscored the situated nature of individual judgments exercised by e.g. leaders or managers, our research focuses on how judgments emerge as organizational responses to recurrently emerging moral dilemmas. Accordingly, we study a setting—decision practices in the English healthcare sector—where moral puzzles (to fund or not to fund healthcare for apparently atypical patients) demand ongoing attention and systemic handling. We conducted (and present findings of) a focused ethnography of the ways expert decision-making panels in three health authorities confronted, engaged, and coped with morally perplexed situations. The moral perplexity there lay in that panels were called upon to prudently and demonstrably determine whether a particular patient deserved or not exceptional investment; and do so by taking into consideration the healthcare needs and rights of all patients under the same health system. By adopting a practice perspective (Schatzki, 2002), we develop an analytical account of the effortful accomplishments (sociomaterial activities or intertwined “projects” in practice theory terms), which enabled the recurrent collective exercise of judgments in accordance with publicly recognizable moral expectations—namely notions of fairness. Our main contribution lies in conceptualizing the work of rendering moral judgments as organized pursuits possible and meaningful and hence in complementing current “ecological understandings” of individual judgment-making in organizations

Improving the capabilities of NHS organisations to use evidence : a qualitative study of redesign projects in Clinical Commissioning Groups

Background Innovation driven by authoritative evidence is critical to the survival of England’s NHS. Clinical Commissioning Groups (CCGs) are central in NHS efforts to do more with less. Although decisions should be based on the ‘best available evidence’, this is often problematic, with frequent mismatches between the evidence ‘pushed’ by producers and that used in management work. Our concern, then, is to understand practices and conditions (which we term ‘capabilities’) that enable evidence use in commissioning work. We consider how research gets into CCGs (‘push’), how CCGs use evidence (‘pull’) and how this can be supported (toolkit development). We aim to contribute to evidence-based NHS innovation, and, more generally, to improved health-care service provision. Method Supported by the National Institute for Health Research (NIHR), we conducted semistructured ethnographic interviews in eight CCGs. We also conducted observations of redesign meetings in two of the CCGs. We used inductive and deductive coding to identify evidence used and capabilities for use from the qualitative data. We then compared across cases to understand variations in outcomes as a function of capabilities. To help improvements in commissioning, we collated our findings into a toolkit for use by stakeholders. We also conducted a small-scale case study of the production of evidence-based guidance to understand evidence ‘push’. Results Fieldwork indicated that different evidences inform CCG decision-making, which we categorise as ‘universal’, ‘local’, ‘expertise-based’ and ‘trans-local’. Fieldwork also indicated that certain practices and conditions (‘capabilities’) enable evidence use, including ‘sourcing and evaluating evidence’, ‘engaging experts’, ‘effective framing’, ‘managing roles and expectations’ and ‘managing expert collaboration’. Importantly, cases in which fewer capabilities were recorded tended to report more problems, relative to cases in which needed capabilities were applied. These latter cases were more likely to effectively use evidence, achieve objectives and maintain stakeholder satisfaction. We also found that various understandings of end-users are inscribed into products by evidence producers, which seems to reflect the evolving landscape of the production of authoritative evidence. Conclusions This was exploratory research on evidence use capabilities in commissioning decisions. The findings suggest that commissioning stakeholders need support to identify, understand and apply evidence. Support to develop capabilities for evidence may be one means of ensuring effective, evidence-based innovations in commissioning. Our work with evidence producers also shows variation in their perceptions of end users, which may inform the ‘push’/’pull’ gap between research and practice. There were also some limitations to our project, including a smaller than expected sample size and a time frame that did not allow us to capture full redesign projects in all CCGs. Future work With these findings in mind, future work may look more closely at how information comes to be treated as evidence and at the relationships of capabilities to project outcomes. Going forward, knowledge, especially that related to generalisability, may be built by means of a longer time and the study of redesign projects in different settings

Evidence-based commissioning in the English NHS : who uses which sources of evidence? A survey 2010/2011

Objectives: To investigate types of evidence used by healthcare commissioners when making decisions and whether decisions were influenced by commissioners’ experience, personal characteristics or role at work. Design: Cross-sectional survey of 345 National Health Service (NHS) staff members. Setting: The study was conducted across 11 English Primary Care Trusts between 2010 and 2011. Participants: A total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey. Main outcome measures: Participants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role. Results: The extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades). Conclusions: Those trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential

The constitutive role of conventions in accomplishing coordination : insights from a complex contract award project

This article advances understanding of how coordination is accomplished in organizations. It builds on and extends recent research, which suggests that coordination is an emergent process of situated interaction aiming to realize a collective performance. In particular, the paper focuses on deliberate efforts to coordinate and contribute to objectives of large-scale integration in practice (e.g., orchestrated, year-long delivery of a megaproject). Such efforts give rise to a novel form of interdependencies, which organizational actors experience as “external” to local activities and group interactions. Drawing on recent developments in social theory, the paper proposes a framework to study coordinative action in situations where organizational actors are faced with a multitude of task-specific and “external” interdependencies. Further, through an in-depth study of a contract award project, it sheds light on the ways ongoing project coordination was adjusted to address interdependencies arising from the deliberate pursuit of two objectives: the concerted delivery of a construction megaproject and the large-scale procurement policy coordination targeted at safeguarding market competition across the European Union. Findings highlight that the situated management of external interdependencies entailed a distinctive type of agency, mediated by formalized industry-wide and policy conventions, and concerned with developing relevant evidence of coordinated contributions. The article explains how and why actors may adjust coordination efforts by alternating between coordination modes. Implications are drawn for studying coordination dynamics in other organizational setting