Towards a sociology of healthcare safety and quality

From embodiment to evidence: The harmful intersection of poor regulation of medical implants and obstructed narratives in embodied experiences of failed metal-on-metal hips

This research presents the results of a study about people with failed metal-on-metal hip implants, and draws on the STS concept of the technological imperative alongside research on the value of patient knowledge in clinical settings and the legitimacy of embodied stories. Popularly understood as positive and life changing, hip replacement surgery was hailed as 'the operation of the century', until a series of widespread failures of hundreds of thousands of hip implants, known collectively as metal-on-metal (MoM) hips, drew attention to the poor regulation of medical implants. This paper argues that poor regulation intersects with narratives of patients' pain, which are obstructed by surgeons and the UK regulatory body, with the effect of denying both patients' embodied experiences of implant failure, and their restitution to good health. Patient narratives about problems with their hip implant are the wellspring from which scientific evidence emerges which can indicate widespread implant failure. By obstructing these narratives the regulatory system undermines the very evidence it needs to operate effectively.

Organization and quality of care in childbirth in private for-profit maternity units in France: Risks of the deprofessionalization of midwives

OBJECTIVE

In France, in 2007-2009, the risk of peripartum maternal mortality, especially the one due to hemorrhage, was higher in the private for-profit maternity units than in university maternity units. Our research, a component of the MATORG project, aimed to characterize the organization of care around childbirth in these private clinics to analyze how it might influence the quality and safety of care.

MATERIAL AND METHODS

We conducted a qualitative survey in 2018 in the maternity units of two private for-profit clinics in the Paris region, interviewing 33 staff members (midwives, obstetricians, anesthesiologists, childcare assistants and managers) and observing in the delivery room for 20 days. The perspective of the sociology of organizations guided our data analysis.

FINDINGS/RESULTS

Our study distinguished three principal risk factors for the safety of care in maternity clinics. The division of labor among healthcare professionals threatens the maintenance of midwives' competencies and makes it difficult for these clinics to keep midwives on staff. The mode of remuneration of both midwives and obstetricians incentivizes overwork by both, inducing fatigue and decreasing vigilance. Finally the clinical decision-making of some obstetricians is not collegial and creates conflicts with midwives, who criticize the technicization of childbirth. Some demotivated midwives no longer consider themselves responsible for patients' safety.

CONCLUSIONS

The organization of work in private maternity units can put the safety of care around childbirth at risk. The division of labor, staff scheduling/planning, and a lack of collegiality in decision-making increase the risk of deprofessionalizing midwives.

"We don't experiment with our patients!" An ethnographic account of the epistemic politics of (re)designing nursing work

This article draws on ethnographic research investigating experimental reform projects in local nursing practices. These are aimed at strengthening nursing work and fostering nurses' position within healthcare through bottom-up nurse-driven innovations. Based on literature on epistemic politics and critical nursing studies, the study examines and conceptualizes how these nurses promote professional and organizational change. The research draws on data from two pilot projects to show how epistemic politics frame the production and use of knowledge within reform efforts. The study finds that knowledge produced through such experimenting is often not considered valid within the contexts of broader organizational transitions. The nurse-driven innovations fail to meet established legitimate criteria for informing change, both among stakeholders in the nurses' socio-political environment, as well as within the nursing community. The research reveals that the processes inadvertently reinforce normative knowledge hierarchies, perpetuating forms of epistemic injustice, limiting both nurses' ability to function as change agents and healthcare organizations' capacity to learn.

"You just want to feel safe when you go to a healthcare professional:" Intimate partner violence and patient safety

Since the early 1990s, researchers and policymakers in the United States have addressed the concept of patient safety in healthcare systems. Traditionally, scholars have conceptualized patient safety as health care that is free from medical error and harm. However, sociologists have called for a more complex understanding of patient safety that includes relational aspects of safety. Although marginalized groups face unique threats to safety, intimate partner violence (IPV) survivors have been largely overlooked within the literature on patient safety. This study addresses that gap. Using the case of IPV, I find that survivors construct healthcare spaces as ideologically safe, but their experiences do not reflect this. Survivors' narratives reveal that patient safety is complex, multi-faceted, and relational. I argue that experiences of safety, or lack thereof, are situated within larger systems of organizational power, relational power hierarchies, and systems of inequalities. These findings have implications when considering how to improve IPV survivors' safety in healthcare settings.

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study

OBJECTIVES

The concept of safety work draws attention to the intentional work of ensuring safety within care systems. Clinical decision support (CDS) has been designed to enhance medication safety in primary care by providing decision-making support to prescribers. Sociotechnical theory understands that healthcare settings are complex and dynamically connected systems of fluid networks, human agents, changing relationships and social processes. This study aimed to understand the relationship between safety work and the use of CDS.

DESIGN AND SETTING

This qualitative study took place across nine different general practices in England. Stakeholders included general practitioners (GPs) and general practice-based pharmacists and nurse prescribers. Semi-structured interviews were conducted to illicit how the system was used by the participants in the context of medication safety work. Data analysis conducted alongside data collection was thematic and drew on socio-technical theory.

PARTICIPANTS

Twenty-three interviews were conducted with 14 GPs, three nurse prescribers and three practice pharmacists between February 2018 and June 2020.

RESULTS

Safety work was contextually situated in a complex network of relationships. Three interconnected themes were interpreted from the data: (1) the use of CDS within organisational and social practices and workflows; (2) safety work and the use of CDS within the interplay between prescribers, patients and populations; and (3) the affordances embedded in CDS systems.

CONCLUSION

The use of sociotechnical theory here extends current thinking in patient safety particularly in the ways that safety work was co-constituted with the use of CDS alerts. This has implications for implementation and use to ensure that the contexts into which such CDS systems are implemented are taken into account. Understanding how alerts can adapt safety culture will help improve the efficacy of CDS systems, enhance prescribing safety and help to further understand how safety work is achieved in primary care.

Involving patients and carers in patient safety in primary care: A qualitative study of a co-designed patient safety guide

BACKGROUND

Involving patients is a key premise of national and international policies on patient safety, which requires understanding how patients or carers want to be involved and developing resources to support this. This paper examines patients' and carers' views of being involved in patient safety in primary care and their views of potentially using a co-designed patient safety guide for primary care (PSG-PC) to foster both involvement and their safety.

METHODS

A qualitative study using semistructured face-to-face interviews with 18 patients and/or carers in primary care. Interviews were transcribed and analysis was conducted using an inductive thematic approach.

RESULTS

Overall participants expressed enthusiasm for the PSG-PC as a tool to support patients and carers to be involved in patient safety in primary care. However, for some participants being involved in patient safety was seen as taking on the role of General Practitioner and had the potential to add an additional workload for patients. Participants' willingness or ability to be involved in patient safety was influenced by a range of factors including an invisible, often underacknowledged role of everyday safety for patients' interactions with primary care; the levels of involvement that patients wanted in their care and safety and the work of embedding the PSG-PC for patients into their routine interactions with primary care. Participants identified components of the PSG-PC that would be useful to them, in particular, if they had a responsibility for caring for a family member if they had more complex care or long-term conditions.

CONCLUSION

Involving patients and carers in patient safety needs a tailored and personalized approach that enables patients and carers to use resources like the PSG-PC routinely and helps challenge assumptions about their willingness and ability to be involved in patient safety. Doing so would raise awareness of opportunities to be involved in safety in line with personal preference.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement were central to the research study. This included working in partnership to develop the PSG-PC with patients and carers and throughout our study including in the design of the study, recruiting participants, interpretation of findings.

Dropdown rights: Categorizing transgender discrimination in healthcare technologies

This study analyzes how U.S. healthcare organizations implemented legal requirements to treat patients in a manner consistent with their gender identity under Section 1557 of the Affordable Care Act. The ways that healthcare organizations determine gender and track complaints constitute socio-technical systems for compliance, and they shape what discrimination protections look like on the ground. We interviewed grievance handlers about how they use information technologies to process possible civil rights claims from patients and argue that their work demobilizes and erases civil rights, especially claims such as transgender harassment. Mobilized physician-led implementation groups, by contrast, enacted a version of gender identity recognition by tracking identities and bodies in electronic medical records and material objects such as specimen labels. Default structures-the dropdown menus of healthcare software-both shape and are shaped by professional norms, financial incentives, and conceptions of justice and deservingness. These socio-technical structures allow conflicting stories of transgender rights to continue on in different parts of the healthcare organization, making it difficult for law to transform healthcare delivery.

Enabling clinician engagement in safety and quality improvement

Objective The aim of this study was to determine how individual, group and leadership factors influence clinician engagement in safety and quality improvement work. Methods The study was conducted through an online questionnaire. Participants were alumni of Australian healthcare safety and quality improvement capability development programs. Relationships between five factors influencing clinicians' perception of value for time and effort in safety and quality improvement work were explored. The five factors were psychological empowerment; task cohesion; social cohesion; transformational leadership behaviour of project leads and sponsors; and value for time and effort for self and patients. Correlation and regression analyses were used to explore the aspects of the hypothesised model. Moderation and mediation analysis was then used to explore the relationships further. Structural equation modelling was used to determine the path model. Results All factors showed strong positive correlations, with psychological empowerment and transformational leadership having the strongest relationships with perceived value for effort for self and patient. The factorial structure of measures was examined, and all indicators loaded significantly on their corresponding latent constructs and the model showed a good fit to the data. Conclusions The findings of this study suggest that the most crucial factor to clinician engagement in safety and quality improvement at the point of care is the leader's behaviour and how that influences team dynamics and individual motivation and empowerment. What is known about the topic? Healthcare organisations remain challenged regarding clinician engagement in safety and quality improvement. Although much is known about clinicians' perceptions of safety and quality, there is more to understand about what practically motivates clinicians to engage. Tapping into individual, group and leadership factors' influences on clinician engagement offers a deeper perspective. What does this paper add? This study explored the individual, group and leadership factors that drive clinician engagement. The factors include the clinician's individual motivation and empowerment to participate, the group dynamics that surround the clinician and the leadership behaviours of the team's leader. The research design allowed for greater understanding about how and to what extent these factors drive clinician engagement. The study's findings can be applied in practice in capability development activities or leadership for safety and quality improvement. What are the implications for practitioners? Rather than taking a perspective that the clinician needs to engage, this study suggests a strong onus on leadership behaviours to engage those clinicians. Focusing on the self as leader and a leader's own behaviours, as well as how those behaviours are fostering positive team dynamics and motivating and empowering individual team members, will have a great benefit on clinician engagement in safety and quality improvement. Higher clinical engagement in safety and quality improvement should translate into better value care.

Interprofessional and multiprofessional approaches in quality improvement education

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Patient experience data as enacted: Sociomaterial perspectives and 'singular-multiples' in health care quality improvement research

Over the last three decades, sociomaterial approaches to the study of health care practices have made an important contribution to the sociology of health care. Significant attention has been paid to the role of technology and artefacts in health care and the operation of actor-networks but less space has been given to questions of ontological multiplicity in health care practices. In this paper, we draw upon our study of patient experience data in five acute hospitals in England to illustrate how treating patient experience data as 'singular-multiples' can enable useful insights into patient experience data work in health care organisations. Our data was generated during 12 months of fieldwork at five participating hospitals and included organisational documents, field notes, informal and formal interviews with frontline and managerial staff and patient representatives at the study sites. We use the examples of the Friends and Family Test (FFT) and the National Cancer Patient Experience Survey (NCPES) in England to consider the multiple nature of data as it is enacted in practice and the work data does when coordinated as an entity in the singular. We argue that, and discuss how, the sociomaterial insights we discuss here are relevant to health care quality and improvement research and practice.

Developing a patient safety guide for primary care: A co-design approach involving patients, carers and clinicians

BACKGROUND

Patients and carers should be actively involved in patient safety and empowered to use person-centred approaches where they are asked to both identify safety concerns and partner in preventing them.

OBJECTIVES

The aim of this study was to co-design a patient safety guide for primary care (PSG-PC) to support patients and carers to address key patient safety questions and identify key points where they can make their care safer. The objectives were to i) identify when and how patients and carers can be involved in primary care patient safety, and ii) identify the relevant information to include in the PSG-PC.

DESIGN

An experience-based co-design approach.

SETTING AND PARTICIPANTS

We conducted three workshops with patients, carers, community pharmacists and general practitioners to develop and refine the PSG-PC.

RESULTS

Participants identified both explicit and implicit issues of primary care patient safety especially relating to technical and relational components of involving patients and carers. The importance of communication, understanding roles and responsibilities, and developing partnerships between patients and health-care providers were considered essential for actively involving patients in patient safety. Co-developing the PSG-PC provided insight to improve care to develop the PSG-PC.

DISCUSSION

The PSG-PC is the first guide to be developed for primary care, co-designed with patients, carers, general practitioners and pharmacists. The PSG-PC will support patients and carers to partner with health-care professionals to improve patient safety addressing international and national priorities to continuously improve patient safety.

Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care

INTRODUCTION

Patients and carers should be active partners in patient safety with healthcare professionals and be empowered to use personalised approaches to identify safety concerns and work together to prevent them. This protocol paper details a study to examine the feasibility of a multicomponent intervention to involve patients and/or carers in patient safety in primary care in the UK.

METHODS AND ANALYSIS

This is a two-phase, non-randomised feasibility mixed methods pragmatic study of a patient safety guide for primary care (PSG-PC). 8 general practices will recruit 120 patient and/or carer participants. All patient and/or carer participants will receive the PSG-PC. It will examine the feasibility and acceptability of the PSG-PC in primary care settings in patients aged 18 years or older who attend appointments at general practice with health professionals four or more times per year as either patients or carers. It will identify secondary outcomes for improving patient safety, health status and patient empowerment, and reducing health service utilisation over 6 months between baseline and 6-month follow-ups. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients and practices will be needed. The study will be undertaken between January 2020 and September 2021.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the National Health Service London-West London and Gene Therapy Advisory Committee Research Ethics Committee (reference: 19/LO/1289). Research findings will be disseminated with participating general practices and shared in a range of different ways to engage different audiences, including presenting at international and national conferences, publishing in open-access, peer-reviewed journals and facilitating dissemination workshops within local communities with patients, carers and healthcare professionals.

TRIAL REGISTRATION NUMBER

ISRCTN90222092.

Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review

PROBLEM

Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models.

BACKGROUND

Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice.

AIM

This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women.

METHODS

A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis.

FINDINGS

Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care.

DISCUSSION

Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible.

CONCLUSIONS

Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.

The role of organizational and professional cultures in medication safety: a scoping review of the literature

PURPOSE

This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of 'cultures' within medication safety and provide an evidence base to shape governance arrangements.

DATA SOURCES

Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS.

STUDY SELECTION

Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by 'culture' or its impact was not discussed.

DATA EXTRACTION

Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety.

RESULTS OF DATA SYNTHESIS

A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term 'culture' was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice.

CONCLUSIONS

Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture.

Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory

OBJECTIVES

Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting.

DESIGN

Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT).

SETTING

Scottish general practice.

PARTICIPANTS

We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland.

RESULTS

We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants' involvement; (3) the characteristics of the reviewers-implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful.

CONCLUSIONS

This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors.

Patient experience: determinants and manifestations

Purpose

Patient experience is a complex multidimensional phenomenon that has been linked to constructs that are also complex to conceptualize, such as patient-centeredness, patient expectations and patient satisfaction. The purpose of this paper is to shed light on the different dimensions of patient experience, including those that receive inadequate attention from policymakers such as the patient’s lived experience of illness and the impact of healthcare politics. The paper proposes a simple classification for these dimensions, which differentiates between two types of dimensions: the determinants and the manifestations of patient experience.

Design/methodology/approach

This paper uses a narrative review of the literature to explore select constructs and initiatives developed for theorizing or operationalizing patient experience. Literature topics reviewed include healthcare quality, medical anthropology, health policy, healthcare system and public health.

Findings

The paper identifies five determinants for patient experience: the experience of illness, patient’s subjective influences, quality of healthcare services, health system responsiveness and the politics of healthcare. The paper identifies two manifestations of patient experience: patient satisfaction and patient engagement.

Originality/value

The paper proposes a classification scheme of the dimensions of patient experience and a concept map that links together heterogeneous constructs related to patient experience. The proposed classification and the concept map provide a holistic view of patient experience and help healthcare providers, quality managers and policymakers organize and focus their healthcare quality improvement endeavors on specific dimensions of patient experience while taking into consideration the other dimensions.

Neither magic bullet nor a mere tool: negotiating multiple logics of the checklist in healthcare quality improvement

Over two decades, the checklist has risen to prominence in healthcare improvement. This paper contributes to the debate between its proponents and critics, making the case for an Science and Technology Studies-informed understanding of the checklist that demonstrates the limitations of both the "checklist-as-panacea" and "checklist-as-socially-determined" positions. Attending to the checklist as a socio-material object endowed with affordances that call upon clinicians to act (Allen 2012, Hutchby 2001), the study revisits the efforts of a recent improvement initiative, the Enhanced Peri-Operative Care for High-risk patients trial. Rather than a singularised simple tool, this study discusses four different and relationally enacted logics of the checklist as a stop and check tool, a clinical prompt, an audit tool and a clinical record. Each logic is associated with specific temporality, beneficiaries, relationship with material forms, and interpellates (Law 2002) clinicians to initiate specific actions which can conflict. The paper seeks to make the case for intervention to improve such tools and consciously account for the consequences of their design and materiality and calls for supporting such settings and arrangements in which incoherences collected in tools can be locally negotiated.

Putting patients into the centre: Patient empowerment in everyday health practices

Patient empowerment is a key topic in public health, medical sociology and in public debates on the modernisation of healthcare. This article joins the on-going discussion on public and patient involvement by offering a patient-centred perspective on patient empowerment outside the usual institutionalised context of chronic disease management. We present results from a qualitative study on individuals' practices of dealing with acute non-life-threatening medical conditions conducted from 2012 to 2017 in Denmark. Based on 34 home visits including in-depth interviews and participant observations with a sample of 28 informants, we uncover a spectrum of four patient tactics governing these practices: delegating, informing, consuming and resisting. The findings suggest disruptive changes to the role of the patient-physician relationship as well as the existence of practices indicative of patient empowerment outside the context of patient empowerment initiatives. Some patients are found to take over responsibility for their health, employing tactics where the role of general practitioners is severely demoted. These empirical contributions lead to the two theoretical contributions of the article: an extension of an existing model of patient empowerment and a conceptual reconsideration of patient empowerment, advocating viewing it as emerging from a bricolage of tactical interactions with social environments rather than as the consequence of an external strategic process.

Comparing the old to the new: A comparison of similarities and differences of the accreditation standards of the chiropractic council on education-international from 2010 to 2016

Background

Chiropractic programs are accredited and monitored by regional Councils on Chiropractic Education (CCE). The CCE-International has historically been a federation of regional CCEs charged with harmonising world standards to produce quality chiropractic educational programs. The standards for accreditation periodically undergo revision. We conducted a comparison of the CCE-International 2016 Accreditation Standards with the previous version, looking for similarities and differences, expecting to see some improvements.

Method

The CCE-International current (2016) and previous versions (2010) were located and downloaded. Word counts were conducted for words thought to reflect content and differences between standards. These were tabulated to identify similarities and differences. Interpretation was made independently followed by discussion between two researchers.

Results

The 2016 standards were nearly 3 times larger than the previous standards. The 2016 standards were created by mapping and selection of common themes from member CCEs' accreditation standards and not through an evidence-based approach to the development and trialling of accreditation standards before implementation. In 2010 chiropractors were expected to provide attention to the relationship between the structural and neurological aspects of the body in health and disease. In 2016 they should manage mechanical disorders of the musculoskeletal system. Many similarities between the old and the new standards were found. Additions in 2016 included a hybrid model of accreditation founded on outcomes-based assessment of education and quality improvement. Both include comprehensive competencies for a broader role in public health. Omissions included minimal faculty qualifications and the requirement that students should be able to critically appraise scientific and clinical knowledge. Another omission was the requirement for chiropractic programs to be part of a not-for-profit educational entity. There was no mention of evidence-based practice in either standards but the word 'evidence-informed' appeared once in the 2016 standards.

Conclusions

Some positive changes have taken place, such as having bravely moved towards the musculoskeletal model, but on the negative side, the requirement to produce graduates skilled at dealing with scientific texts has been removed. A more robust development approach including better transparency is needed before implementation of CCE standards and evidence-based concepts should be integrated in the programs. The CCE-International should consider the creation of a recognition of excellence in educational programs and not merely propose minimal standards.

"It's better to have three brains working instead of one": a qualitative study of building therapeutic alliance with family members of critically ill patients

Background

Studies in the intensive care unit (ICU) suggest that better communication between families of critically ill patients and healthcare providers is needed; however, most randomized trials targeting interventions to improve communication have failed to achieve family-centered outcomes. We aim to offer a novel analysis of the complexities involved in building positive family-provider relationships in the ICU through the consideration of not only communication but other important aspects of family-provider interactions, including family integration, collaboration, and empowerment. Our goal is to explore family members’ perspectives on the enablers and challenges to establishing therapeutic alliance with ICU physicians and nurses.

Methods

We used the concept of therapeutic alliance as an organizational and analytic tool to conduct an interview-based qualitative study in a 20-bed adult medical-surgical ICU in an academic hospital in Toronto, Canada. Nineteen family members of critically ill patients who acted as substitute decision-makers and/or regularly interacted with ICU providers were interviewed. Participants were sampled purposefully to ensure maximum variation along predetermined criteria. A hybrid inductive-deductive approach to analysis was used.

Results

Participating family members highlighted the complementary roles and practices of ICU nurses and physicians in building therapeutic alliance. They reported how both provider groups had profession specific and shared contributions to foster family communication, integration, and collaboration, while physicians played a key role in family empowerment. Families’ lack of familiarity with ICU personnel and processes, physicians’ sporadic availability and use of medical jargon during rounds, however, reinforced long established power differences between lay families and expert physicians and challenged family integration. Family members also identified informal interactions as missed opportunities for relationship-building with physicians. While informal interactions with nurses at the bedside facilitated therapeutic alliance, inconsistent and ad-hoc interactions related to routine decision-making hindered family empowerment.

Conclusions

Multiple opportunities exist to improve family-provider relationships in the ICU.

The four dimensions of therapeutic alliance prove analytically useful to highlight those aspects that work well and need improvement, such as in the areas of family integration and empowerment.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3341-1) contains supplementary material, which is available to authorized users.

'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice

Background

Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks.

Methods

A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed.

Results

Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment.

Conclusion

The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so.

Improvement Science Meets Improvement Scholarship: Reframing Research for Better Healthcare

In this editorial essay I explore the possibilities of 'improvement scholarship' in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement (QI) research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between 'problem-solving' and 'critical' currents in improvement research. I have in mind the potential for building a much larger conversation between those people in 'improvement science' who are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the 'implicit normativity' of QI research and practice, and the linked theme of combining relatively 'tidy' and potentially 'unruly' forms of knowledge.

Analysing healthcare coordination using translational mobilization

Purpose

The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes.

Design/methodology/approach

TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case.

Findings

TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning.

Originality/value

Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

Titrating the Rig: How Paramedics Work in and on Their Ambulance

In this article, I take readers inside of an ambulance and explore how paramedics work in and on their "apparatus unit" to make it a workable fit. This taken-for-granted work is important because much is at stake in the back of the ambulance, particularly in relation to quality of care and safety. I draw on data from an institutional ethnography into the socially organized work and work settings of paramedics, which included more than 200 hr of observations and more than 100 interviews with paramedics. The findings shed light on the situated work processes of paramedics as they orient and respond to their "apparatus unit" and enact quality and safety in practice. This article adds to the sociological literature on work and occupations as well as safety and quality in health care of an increasingly important group of health care and emergency services professional.

Medical directors’ perspectives on strengthening hospital quality and safety

Purpose

The purpose of this paper is to understand the concerns and factors that impact on hospital quality and safety, particularly related to use of performance data, within a setting of devolved governance.

Design/methodology/approach

This qualitative study used thematic analysis of interviews with public hospital medical directors. For additional context, findings were framed by themes from a review of hospital safety and quality in the same jurisdiction.

Findings

Varying approaches and levels of complexity were described about what and how performance data are reviewed, prioritised, and quality improvements implemented. Although no consistent narrative emerged, facilitators of improvement were suggested relating to organisational culture, governance, resources, education, and technologies. These hospital-level perspectives articulate with and expand on the system-level themes in a state-wide review of hospital safety and quality.

Research limitations/implications

The findings are not generalisable, but point to an underlying absence of system-wide agreement on how to perceive, retrieve, analyse, prioritise and action hospital performance data.

Practical implications

Lack of electronic medical records and an inefficient incident reporting system limits the extent to which performance and incident data can be analysed, linked and shared, thus limiting hospital performance improvement, oversight and learning.

Social implications

Variable approaches to quality and safety, standards of care, and hospital record keeping and reporting, mean that healthcare consumers might expect inconsistency across Victorian hospitals.

Originality/value

The views of medical directors have been little researched. This work uses their voice to better understand contextual factors that situate and impact on hospital quality and safety towards understanding the mixed effectiveness of hospital quality improvement strategies.

Technical rationality and the decentring of patients and care delivery: A critique of 'unavoidable' in the context of patient harm

In recent decades, debate on the quality and safety of healthcare has been dominated by a measure and manage administrative rationality. More recently, this rationality has been overlaid by ideas from human factors, ergonomics and systems engineering. Little critical attention has been given in the nursing literature to how risk of harm is understood and actioned, or how patients can be subjectified and marginalised through these discourses. The problem of assuring safety for particular patient groups, and the dominance of technical forms of rationality, has seen the word 'unavoidable' used in connection with intractable forms of patient harm. Employing pressure injury policy as an exemplar, and critically reviewing notions of risk and unavoidable harm, we problematise the concept of unavoidable patient harm, highlighting how this dominant safety rationality risks perverse and taken-for-granted assumptions about patients, care processes and the nature of risk and harm. In this orthodoxy, those who specify or measure risk are positioned as having more insight into the nature of risk, compared to those who simply experience risk. Driven almost exclusively as a technical and administrative pursuit, the patient safety agenda risks decentring the focus from patients and patient care.