Balatsas-Lekkas, Angelos

Yoshinaka, Yutaka

English

Health care, as situated practices of the everyday, unfolds in concrete settings, which are nevertheless influenced by ongoingorganizational agendas, and diverse in origin and timeframes. Patient safety practices are no exception – but how do practicesof local settings relate to the overall sense-making and articulation of work that takes place in the institution? What productivework can be discerned in the situated practices of patient safety and quality health care, i.e. also in the broader framing of theactivities, beyond the confines of the specific locality of action? The present paper examines the refiguring effects of patientsafety practices (Zuiderent-Jerak, et al. 2009; Pedersen 2017). From the relatively delimited contexts of their originalengagement, scrutiny is also given to ‘less visible’, perhaps ‘deleted’, organizational configurations in which patient safetypractices continue to perform. The paper draws on the notion of artful contamination (Zuiderent-Jerak and Jensen 2009),through which patient safety becomes enmeshed in the organizing of the institutional framework of a health care setting. Evenwhere patient safety does not figure as an explicit concern, it is thus seen to serve a role. The study points to the practicalsignificance of such translations in and for clinical practices.The objective of the study is to foreground the transformative potential of patient safety in organizing and reordering processesof healthcare work. With the healthcare practitioner in focus, the study points to the significance of their clinical work, yet alsointo matters of learning and interplay between professionals, work, and, more broadly, projects of the organization.The paper takes a retrospective approach, ex post case analyses of projects conducted in collaboration with a Maternal-ChildCare facility of a Danish hospital. The projects relate to neonatal milk kitchen and pediatric surgery ward practices. Sensitizingconcepts informed by Science and Technology Studies and generative design research are leveraged to explore and make senseof the relationships between the in situ and accomplished character of patient safety practices on the one hand, and acrosstheir immediate sites of action on the other (Nicolini 2012).Intervening capacities of safety practices in their further enmeshment points to the trade-offs or “artful contamination” throughwhich safety becomes a sustained, albeit less-pronounced, aspect of manifold processes in the agendas and work. Patientsafety initiatives manifest through other means, albeit not with the original problem-framing of patient safety and quality healthcare as being a key concern. It points to the unfolding of ‘patient safety’ practices and their partial connections in making theirrelevance in manifold ways. Such an irreductive vantage point in addressing and working with patient safety allows foropenness and flexibility to be leveraged, and in drawing on distribution of safety work in other practices.The study shows the relevance of patient safety practices as sustained beyond the scope and framing of the immediacy ofclinical practice. Through empirical synthesis, it shows how patient safety practices can be discerned as pertinent to diverseagendas of the organization.References• Nicolini, D. (2012). Practice Theory, Work, and Organization. Oxford: Oxford University Press.• Pedersen, K. Z. (2017). Organizing Patient Safety. London: Palgrave Macmillan.• Zuiderent-Jerak, T. &amp; Jensen, B., C. (2009). Editorial introduction: Unpacking ‘intervention’ in Science and TechnologyStudies. Science as Culture 16(3): 227-235.• Zuiderent-Jerak, T., Strating, M., Nieboer, A. and Bal, R. (2009). Sociological refigurations of patient safety:Ontologies of improvement and ‘acting with’ quality collaboratives in health care. Social Science &amp; Medicine 69(9):1713-21

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This document is downloaded from theVTT’s Research Information Portalhttps://cris.vtt.fiVTThttp://www.vtt.fiP.O. box 1000FI-02044 VTTFinlandBy using VTT’s Research Information Portal you are bound by thefollowing Terms & Conditions.I have read and I understand the following statement:This document is protected by copyright and other intellectualproperty rights, and duplication or sale of all or part of any of thisdocument is not permitted, except duplication for research use oreducational purposes in electronic or print form. You must obtainpermission for any other use. Electronic or print copies may not beoffered for sale.VTT Technical Research Centre of FinlandEnmeshing patient safety – intervening in the organization and practicesof careBalatsas-Lekkas, Angelos; Yoshinaka, YutakaPublished: 01/01/2018Link to publicationPlease cite the original version:Balatsas-Lekkas, A., & Yoshinaka, Y. (2018). Enmeshing patient safety – intervening in the organization andpractices of care. 82. Poster session presented at 5th Nordic Conference on Research in Patient Safety andQuality in Healthcare, Copenhagen , Denmark.Download date: 28. Apr. 2020.ConclusionResultsBackgroundEnmeshing patient safety –intervening in the organization and practices of careAngelos Balatsas-LekkasVTT Technical Research Centre of Finland LtdExt-Angelos.Balatsas-Lekkas@vtt.fiYutaka Yoshinaka DTU Management Engineering, Technical University of Denmarkyosh@dtu.dk With the healthcare practitioners in focus, thestudy points to the significance of their clinicalwork, also into matters of learning and interplaybetween professionals, work and, more broadly,projects of the organization.The paper takes a retrospective approach, expost case analyses of projects conducted incollaboration with a Maternal-Child Care facilityof a Danish hospital. The projects concern theprevention of adverse events:1) in a neonatal milk kitchen; and2) in indoor hospital playrooms, respectively.Sensitizing concepts informed by Scienceand Technology Studies (STS) and generativedesign research are leveraged, towardsexploring and making sense of relationshipsbetween the in situ, accomplished characterof patient safety practices, vis-à-vis practicesacross the immediate sites of such action.Our study points to the unfolding of ‘patientsafety’ practices and their partial connections inmaking their relevance in manifold ways. Suchan irreductive vantage point in addressing andworking with patient safety allows for opennessand flexibility to be leveraged, and in drawing ondistribution of safety work in other practices(Balatsas-Lekkas 2016). Intervening capacitiesof safety practices in their further enmeshmentpoints to “artful contamination” (Zuiderent-Jerakand Jensen 2009) through which safety becomesa sustained, albeit less-pronounced aspect ofmanifold processes in the agendas and work.Patient safety initiatives manifest through othermeans, albeit not with the original problem-framing of patient safety and quality health careas being a key concern.For examining the refiguring effects of patientsafety practices (Zuiderent-Jerak, et al. 2009;Pedersen 2017) the paper draws on thenotion of “artful contamination” (Zuiderent-Jerak and Jensen 2009), to provide an analysisof how patient safety becomes enmeshed in theorganizing of the institutional framework of ahealth care setting. From the relatively delimitedcontexts of the original engagement of safetypractices, “artful contamination” allows alsoscrutiny to ‘less visible’, perhaps ‘deleted’,organizational configurations in which patientsafety practices continue to perform.The transformational, productive process ofreciprocal influences in the contexts of theorganization - both intended and otherwise - arehereby broached. “Artful contamination”,invoking as a notion that of “artful integration”(Suchman 2002) related to design, lends in theanalysis sensitivity to the accomplished yetalways indeterminate, provisional character ofprofessional work and tasks, including plans andprojects in their undertaking. Thus, the analysispoints to the practical significance of suchtranslations in and for clinical practices. Balatsas-Lekkas, A. (2016). Assemblages of Patient Safety. Bringing together matters of concern between design and multiple knowledgepractices in healthcare. Ph.D Thesis at the department of Management Engineering, Technical University of Denmark. Pedersen, K. Z. (2017). Organizing Patient Safety. London: Palgrave Macmillan. Simonsen, B. & Beck, S. A. (2012) Det gode mælkekøkken - indretning, der inviterer til rigtige arbejdsprocesser. Symposiebogen -Rigshospitalets Sygeplejesymposium, juni 2012, p. 18-21. Suchman, L. (2002). Located accountabilities in technology production. Scandinavian Journal of Information Systems, 14(2): 91-105. Zuiderent-Jerak, T. & Jensen, B., C. (2009). Editorial introduction: Unpacking ‘intervention’ in Science and Technology Studies. Science as Culture 16(3): 227-235. Zuiderent-Jerak, T., Strating, M., Nieboer, A. and Bal, R. (2009). Sociological refigurations of patient safety: Ontologies of improvement and ‘acting with’ quality collaboratives in health care. Social Science & Medicine 69(9): 1713-21.Interdisciplin-ary cleaning practices at  the Maternal-Child care facility1. Hygiene as a multiple concern for non clinical professionals: Pedagogues, ward cleaners, teachers entertainers & librarians.2. Pedagogues as exampleEngaging parents of young patients and ward cleaners in cleaning practices through the treating of toys as “clean” or “unclean” objects.3. In-situ use of hygiene systemsalong with thedevelopment and use of additionalartifacts, such as posters, signs and ”hygiene corners”.4.  Temporarytrasformationof isolation roomsinto ”classrooms”  and of educationalmaterial as ”cleanenough” objects.References AcknowledgementWe would like to acknowledge the kind contributions of staff at Juliane Marie Centre, Rigshospitalet –Copenhagen University Hospital, for making possible the empirical undertakings (conducted 2012,2015), on which this post hoc analysis is based.1. Hygiene is a concern forvarious professionals involved inplay and educational activities ofyoung patients. While workingwithin play areas and patientrooms, pedagogues, teachers,ward cleaners, librarians andentertainers are also concernedwith the hygenic status of objectsthat relate to their professionalpractices, such as toys for thepedagogues and enducationalmaterial for teachers. Moreover,non-clinical professionals developtaks and processes for cleaningthat allows them to accomplishthe objectives of their professionalrole (e.g. play at playroomsrequires the use of clean toys andthe cleaning of used toys afterplay) while also use systems andparticipating to cleaning practicesdeveloped and implemented bythe hospital’s hygiene department.2. Pedagogues ensure that withinplayrooms each toy is treated as a”clean” or ”unclean” object. Afterused in individual or collective playactivities, toys must be either”cleaned” or marked as ”unclean”and stored as such, away fromchildren’s reach. For ensuring thatthe ”clean”\”unclean” treatment oftoys continues even in hours thatplayrooms function without theactual presence of pedagogues,the latter engage parents of youngpatients and ward cleaners in theidentification, cleaning, storing andseparation of ”clean” and ”unclean”toys. Pedagogues’ continousspotting and informing of parentsof recelty admited young patientsand of new ward cleaners aboutthe treatment of hygiene concenrsin playrooms allows them to”artfully integrate” new actors inhygiene maintainance.4. With support from the hygienedepartment, the teachers of youngisolated patients have developed aprocess for transforming isolationrooms into ”temporaryclassrooms”. Prior to entering intoan isolation room, teachers takestandard isolation precautions, asrequested from the hygienedepartment (e.g. wearing gowns,gloves and huts) while they alsouse a variety of hygiene-relatedartifacts (e.g. disinfection gel) andothers (e.g. photocopied excerptsof educational books) forproducing ”clean enough”educational material for single useat the isolation rooms. Teachingand hygiene maintenance becomeenmeshed-but also achieved-through the mutual shaping ofteaching and hygiene practicesand, therefore the formation of aninterdisciplinary safety practice.Case Analysis 1: Neonatal milk kitchenCase Analysis 2: Hygiene and playMethodsObjectiveTheoretical framework3. Developed by the hygienedepartment of the hospital, asystem of a green and a red plasticbox for storing ”clean” and”unclean” toys, respectively, isinstalled within each of the facility’splayrooms. Aiming at the sustaineduse of the system by variousplayroom users (e.g. parents andcleaners), pedagogues havedeveloped for and installed in eachplayroom additional artifacts. Forexample:A) signs that inform playroom’susers (e.g. parents and relatives)that used toys entail hygiene-related risks, B) instructions forcleaning used toys with availablematerials, C) designated areas fortoy cleaning, refered as ”hygienecorners”. The above suggest thatthe development and use ofadditional artifacts clarifies thepurpose of the box system for eachactor while also generates ashared cleaning practice that isenmshed into the work of variousprofessionals rather than to justsafety experts.Health care practices unfold in concrete settings,which, themselves, are influenced by ongoingorganizational agendas, diverse in origin andtimeframes. To address how safety practicesrelate to the overall sense-making andarticulation of work that take place in theinstitution, the study approaches productive workthat can be discerned in the situated practices ofpatient safety and quality health care. Thisincludes such work pertaining also to patientsafety, albeit, beyond the specific locality ofaction.The handling of mothers’ breastmilk is a process that isundertaken up to 300 times a dayat the case facility - a Mother-ChildCare setting. Premature babieshospitalized there require feedingup to 12 times a day each, withborh nurses as well as parentsundertaking tasks entailed - thecollection, storage, retrieval andother aspects of handling suchbreast milk. A completed analysiscarried out by the Hospital, lookinginto the aggregate root-causes forreported adverse events inconnection with the handling, hadpointed to the possibility of makingimprovements through work of re-designing the interiors of refrid-girataion (and freezer) units in themilk kitchens. It was deemed theywere prone to inadvertent,switching of breast milk prior touse. (Simonsen and Beck, 2012)This problem-framing served as abackdrop for a collaborativeproject between the case facilityand a team of design engineeringuniversity students and theirsupervisor, spanning five months.Generative design researchmethods were engaged, to helpunderstand issues and possibilitiesin situ. First-hand ethnographicfield work in the facility allowedgaining deep knowledge andtaking stock of insight to the breastmilk handling practices, and toleveraging toward co-designingactivities with health careprofessionals (see images below).The original scope and framing tore-design refrigiration units per se,were opened up through thecollaboration to scrutinizing, butalso leveraging, breast milkhandling practices across theentirety of ’the journey’ of thebreast milk - the ’hands’, theprops, and situations, all whichbear upon its handling. It broachedmore than what may reduced topatient safety in a clear-cutmanner – and reframed the issuemore conducively as manifoldpractices in many different situa-tions of potential pertinence toquality in breast milk handling.Design materials issuing from thisprocess allowed for activelyAbove: A parent to an inpatient premature baby inthe process of transferring the mother’sbreastmilk into an individualized receptacle forstorage, and marking it for future identificationbefore storing in the milk kitchen refridgirator.Below: Image taken from one of the co-designsessions between hospital personnel and universityproject team with design engineering students – ingenerative design research and qualifying solutions.engaging participants in hands-onco-design processes. Ethnogra-phic research findings, reframingproblem focus as well asopportunities toward improvement,were followed by ideation, andconcept detailing, resulting in threedistinct holistic proposals.While the proposed solutions wereconceptualised as distinct project-undertakings, the case settingopted to subsequently reconfigureselected elements from all threeproposals into partial solutionsfurther borne through theorganization with intitiativesalready carrying currency. Ratherthan a patient safety project per seto reorganize handling of breastmilk, elements from the collabo-ration were enmeshed in concur-rent initiatives, with otherorganizational players, makingthem realizable. Patient safetythus affected, but also wasinfluenced through, organizationalinitiatives in realizing the solutions.The study shows the relevance of patient safetypractices as sustained beyond the scope andframing of the immediacy of clinical practice.Through empirical synthesis, it shows howpatient safety practices can be discerned aspertinent to diverse agendas of the organization.

Enmeshing patient safety – intervening in the organization and practices of care

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Enmeshing patient safety – intervening in the organization and practices of care

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