Year: 2011
Type: dissertation
Abstract: Over the past decade, patient safety has emerged as a major issue in hospitals, arising \nfrom reports of unacceptable levels of harm to patients caused by the process of health \ncare itself rather than any underlying disease. A growing research movement has \ndeveloped around finding out why so much harm occurs, and what can be done to \nreduce it. The ever-increasing complexity of health care provision is consistently cited \nas an underlying factor, and alongside calls for more accountability and transparency, \nformal systems of accountability such as guidelines and incident reporting have \nemerged in response, designed to govern frontline activities and to manage complexity \nthrough standardisation. As popular as these approaches are however, they are also \ncontroversial, and a large subset of patient safety research is focused on identifying and \novercoming local ‘barriers’ to their implementation. \nIn this thesis, I analyse the problematic implementation of this formal accountability \nand challenge its assumptions. I propose that we insufficiently understand how safety is \ncurrently practiced by clinicians, and likewise, how accountability is practiced. My \nthesis therefore focuses on exploring safety and accountability as practices. I describe \naccountability not only in formal terms, but also as informal and everyday talk and \nbehaviour. Furthermore, I propose that the problems of implementation described above \ncan be reframed instead as tensions between accountabilities. In this study therefore, I \nexamine how clinicians negotiate multiple accountabilities in their practices of safety. \nWith a multidisciplinary group of 72 clinicians in a children’s hospital in New South \nWales, Australia, I created ethnographic data through observations, field interviews and \nfeedback sessions in two phases of field work, over ten months in total. Following each \nphase, data were iteratively coded and analysed using a grounded theory approach. \nWith these data, I show how clinicians are enacting safety through their practices of \naccountability, in contexts complicated by multiple accountabilities and multiple \nmeanings of safety. I show how clinicians inevitably produce accounts that are partial \nand ‘incomplete’, at risk of becoming problematically disembedded from complexity. I \nalso show how clinicians are re-embedding these partial accounts, by engaging in \naccountability practices that foreground multiplicity, diversity and reciprocity. I argue \nthat if we wish for practices of accountability to reflect and support clinical practices \nthat we see as complex and interconnected, then we need to embrace more complex and \ninterconnecting practices of accountability. Rather than calling for more accountability, \nwe need to practice more accountabilities instead, to increase the reciprocal and \nreflexive engagement of participants with one another in (and beyond) the health care \nsystem. In doing so, we would enable care that is ‘safer’ by enabling more people to \nparticipate more variously and directly in negotiating the complexity and shifting \nboundaries of health care delivery.
Author: Su-yin Hor
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
Funder: University of Technology Sydney
OpenAlex ID: W2288416368