Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare☆
Section snippets
Introduction: articulating agendas of (researching) patient safety
Over the last decade, patients, policy makers and clinicians are being made increasingly aware that hospitals and other care institutions are risky places. Starting with the seminal report To Err is Human: Building a Safer Health System (Committee on Quality of Health Care in America, 2000) by the American Institute of Medicine, and following a series of other reports and white papers published by American and European institutions, healthcare improvement advocates have redefined healthcare
‘Usefulness’ and multiple ontologies in the social sciences
Within medical sociology – as within other strands of the social sciences – there are increasing pleas for researchers to ‘get real’ (Bal, Hendriks, & Bijker, 2004) and leave their classical critical position that make them seem “like those mechanical toys that endlessly make the same gesture when everything else has changed around them” (Latour, 2004, p. 225). Such calls for more productive forms of sociological analysis can also be found in the methodological literature on (medical)
Studying the care for better quality and safety improvement collaborative
The improvement collaborative we are studying was launched in October 2005 by the Dutch Ministry of Health. This large-scale improvement program for the care sectors was a part of the national action program for quality, innovation and efficiency run by the Ministry. This improvement collaborative, called Care for Better, followed from recent Dutch as well as international debates showing great concern for patient safety in the care sectors (cf. Leape et al., 2006). Quality improvement
Unpacking ‘effectiveness’ in medication safety
The effectiveness of quality improvement collaboratives is generally defined as ‘targets realized’ and displayed in the quantitative format of measured performance. About two months after the initial meeting there is typically a first working conference in which improvement teams are familiarized with notions that form part of the ‘grammar’ of performance management, such as the distinction between structure-, process- and outcome indicators (Donabedian, 2005), the notion of defining targets
Complexifying agendas for ‘client participation’ in patient safety
In safety improvement in healthcare, as well as in other domains of the quality improvement movement, there have been strong pleas for involving clients in redesigning care. Slogans like “Nothing about me without me” (Ashton & Richards, 2003) with their appeal of it being a “no-brainer” not to involve patients and clients (CrosskeysMedia, 2004) have been consequential for the setup of collaboratives for safety improvement. Though in the Netherlands there are no legal obligations to include
Exploring the potential of interventionist evaluation; refiguring usefulness
Based on our previous experience with studying quality and safety improvement in healthcare (Bal and Mastboom, 2007, Zuiderent-Jerak, 2007, Zuiderent-Jerak, (2009)) we were aware that it would be neither possible nor desirable to avoid intervening in the improvement collaborative through our research practices. We chose to turn this situation, which is traditionally associated with ‘confusing roles’ of evaluators and executors (Bate & Robert, 2002), into an explicit aim of the study design.
Conclusions: ontologies of (studying) patient safety
We hope to have shown that studying patient safety with a focus on multiple ontologies provides a productive alternative to the narrow definition of ‘usefulness’ outlined at the outset of this paper. Where utilistic renderings of safety researchers restrict the acting space of sociologists to finding factors that hinder improvement and measures to assess it, analyzing multiple ontologies in improvement practices explores the potential of sociologists for productively refiguring the problem
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We wish to thank the quality improvement agents form the Care for Better quality collaborative for their dedication and interest in this shared journey. We also wish to thank Annemiek Stoopendaal for sharing one of her observations of an improvement team meeting where we were presenting, Nina Boulus, Casper Bruun Jensen and the anonymous reviewers from SSM for their careful and thoughtful feedback to an earlier version of this paper. This research is funded by a research grant of ZonMw.