Elsevier

Social Science & Medicine

Volume 69, Issue 12, December 2009, Pages 1713-1721
Social Science & Medicine

Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare

https://doi.org/10.1016/j.socscimed.2009.09.049Get rights and content

Abstract

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of ‘usefulness’ in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of ‘usefulness’, this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of ‘effective care’ are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study.

In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like ‘effectiveness’ and ‘client participation’ are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many ‘implementation problems’ presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for ‘acting with’ quality improvement agents.

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

References (57)

  • C. Barry et al.

    Using reflexivity to optimize teamwork in qualitative research

    Qualitatve Health Research

    (1999)
  • P. Bate et al.

    Studying health care “quality” qualitatively: the dilemmas and tensions between different forms of evaluation research within the U.K. National Health Service

    Qualitatve Health Research

    (2002)
  • Committee on Quality of Health Care in America

    To err is human: building a safer health system

    (2000)
  • Committee on Quality of Health Care in America

    Crossing the quality chasm: A new health system for the 21st century

    (2001)
  • CrosskeysMedia

    Involving patients in redesigning care. Pursuing perfection in health care U.S.A

    (2004)
  • A. Donabedian

    Evaluating the quality of medical care

    The Milbank Quarterly

    (2005)
  • L. Donaldson

    Championing patient safety: going global

    Quality & Safety in Health Care

    (2002)
  • R.v. Geenen

    Aanval op medische missers

    (2005)
  • R. Grol et al.

    Quality improvement research; understanding the science of change in health care

    Quality & Safety in Health Care

    (2002)
  • E.G. Guba et al.

    Fourth generation evaluation

    (1989)
  • D. Hess

    Ethnography and the development of science and technology studies

  • Hills, D. (2001). Action Research as a component of evaluation. Presentation at National Co-ordinating Centre for...
  • R. Iedema et al.

    Surveillance, resistance, ovservance: exploring the teleo-affective volatility of workplace interaction

    Organization Studies

    (2006)
  • C.Bruun Jensen

    Sorting attachements: on intervention and usefulness in STS and health policy

    Science as Culture

    (2007)
  • C.Bruun Jensen

    Sociology, systems and (patient) safety; knowledge translations in healthcare policy

    Sociology of Health & Illness

    (2008)
  • C.M. Kilo

    A framework for collaborative improvement: lessons from the institute for healthcare improvement's breakthrough series

    Quality Management in Health Care

    (1998)
  • T.S. Kuhn

    The function of measurement in modern physical science

  • B. Latour

    Why has critique run out of steam? From matters of fact to matters of concern

    Critical Inquiry

    (2004)
  • Cited by (0)

    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.

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