Elsevier

Safety Science

Volume 67, August 2014, Pages 50-57
Safety Science

Seeing patient safety ‘Like a State’

https://doi.org/10.1016/j.ssci.2014.02.007Get rights and content

Highlights

  • Safety management efforts in healthcare parallel important improvement efforts in public policy.

  • This suggests similar foundational assumptions in both.

  • These assumptions tend to devalue local practical knowledge in the workplace.

  • Failure to recognize and address these assumptions can lead to ineffective safety efforts.

  • Similar foundational assumptions underlie safety management efforts in other industries.

Abstract

This paper examines how the syndrome of authoritarian high modernism, described in detail in the public policy sphere in James C Scott’s Seeing Like a State, serves as the dominant, orthodox ideology informing patient safety. We compare Scott’s conceptual framework to the currently dominant health care safety practices to surface foundational issues that would otherwise remain hidden, but which need to be revealed to make progress in safety. Although the paper focuses on safety in healthcare as a particular, specific exemplar, the elements of the syndrome are relevant to orthodox safety efforts in many hazardous activities.

Introduction

“There is no such thing as philosophy-free science; there is only science whose philosophical baggage is taken on board without examination” (Dennett, 1995).

In health care, the term syndrome (from Greek σύνδρομος, “running together”) describes a collection of several recognizable features or characteristics that are often seen together; their relationship may not be causal, or even known, but their co-presence constitutes a usefully recognizable pattern. This paper uses the syndrome concept as a metaphor to describe a pattern of characteristics common to orthodox thinking about safety, and relates it to a complex of features previously described as “authoritarian high modernism” in Scott’s monograph Seeing Like a State (Scott, 1998). Briefly, authoritarian high modernism is a movement characterized by a hubristic faith in the program of technical rationality (Schön, 1982) that privileges central, explicit, technical knowledge over local, tacit, practical know-how (Holmes et al., 2008, Jerak-Zuiderent, 2012), and enforces that privileging through some means of power. It is a specific instance of a much larger body of thought about the role of reason in organizing affairs. This paper will argue that in both its assumptions and its methods, much of the orthodox thinking about patient safety parallels and re-enacts authoritarian high modernism. But in Scott’s view, authoritarian high modernism is implicated in some remarkable failures (e.g., the unliveable design of Brasília, China’s Great Leap Forward, the collectivization of the Ukraine and resulting famine in the 1930s); these parallels offer a sobering cautionary tale for those interested in improving safety.

Previous critiques of what might be called the “safety orthodoxy” (Clarke and Short, 1993, Dekker et al., 2011, Dekker et al., 2013, Hollnagel et al., 2006, Rochlin, 1999, Rowley and Waring, 2011b, Woods and Cook, 2002, Zuiderant-Jerak and Berg, 2010) have not specifically connected to this framework, although both these critiques and Scott’s conceptual model both stem from the same much larger, richer, and abundant social and intellectual sources. By analyzing mainstream safety thinking through the lens of authoritarian high modernism (AHM), we hope to improve insight into the foundations of safety science in relation to social ambitions for greater safety and security, and to contrast the foundational assumptions of orthodox with more modern thinking about safety (Cook, 2010, Hollnagel, 2012, Rasmussen, 1997, Woods and Cook, 1999).

The remainder of the paper is organized into 4 parts. The next section (Section 2) will briefly review the basic elements of authoritarian high modernism as outlined originally by Scott (1998), and will place his framework within a much larger and much older set of sociological and philosophical themes surrounding rationalization, bureaucracy, the ideology of control, and the role of science and reason as governing principles. Section 3 will then describe the current safety orthodoxy in healthcare and use it as a case-in-point to analyse the patient safety movement in terms of the authoritarian high modernist elements, showing how they play out in discourses about safety in that domain. It will advance the notion that the patient safety orthodoxy is to a large extent, another manifestation of authoritarian high modernism. Section 4 will compare healthcare safety to safety efforts in other hazardous industries. It will use this analysis to examine the foundational assumptions underlying orthodox safety efforts, and contrast them to the assumptions associated with more modern views on safety rooted in concepts of emergence, complexity, tradeoffs and local rationality (Grote, 2012). Section 5 will close with a discussion of the limitations of this analysis and the implications for future progress.

Section snippets

Authoritarian high modernism

Authoritarian high modernism is a specific framework (using our metaphor, a syndrome) that is embedded in a much larger, richer, and older managerial, sociological, and philosophical area of study and debate that reaches back for over a century. While even a superficial discussion of these roots is far beyond the scope of this paper, it is important to acknowledge the intellectual provenance of these ideas. Discourses about the role of reason and the nature of science date back to the

Authoritarian high modernism and patient safety

This section examines the way in which each of the four elements of authoritarian high modernism has played out in discourses around healthcare safety.

From patient safety to safety in general

This essay has mostly drawn on safety efforts in healthcare, which is in many ways, a special case where safety interventions are uniquely difficult. Healthcare differs from other hazardous industries in important ways, which may have served to highlight the problems of a high modernist approach. First, healthcare is only now undergoing the process of industrialization that other industries experienced in the 19th and early 20th centuries; thus one might argue that it is recapitulating the

Limitations and conclusion

There is an important limitation to the preceding argument, in that it would be dangerous to interpret it as unconditional approval (even exaltation) of all that currently exists. In his discussion of authoritarian high modernism in policy, Scott points out that the traditional social systems it attempts to displace are not idyllic egalitarian paradises inhabited by Rousseau’s noble savages, but contain their own, sometimes shocking, instances of oppression and hegemony (Scott, 1998).

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