Accountability and patient safety : a study of mess and multiplicities

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Over the past decade, patient safety has emerged as a major issue in hospitals, arising from reports of unacceptable levels of harm to patients caused by the process of health care itself rather than any underlying disease. A growing research movement has developed around finding out why so much harm occurs, and what can be done to reduce it. The ever-increasing complexity of health care provision is consistently cited as an underlying factor, and alongside calls for more accountability and transparency, formal systems of accountability such as guidelines and incident reporting have emerged in response, designed to govern frontline activities and to manage complexity through standardisation. As popular as these approaches are however, they are also controversial, and a large subset of patient safety research is focused on identifying and overcoming local ‘barriers’ to their implementation. In this thesis, I analyse the problematic implementation of this formal accountability and challenge its assumptions. I propose that we insufficiently understand how safety is currently practiced by clinicians, and likewise, how accountability is practiced. My thesis therefore focuses on exploring safety and accountability as practices. I describe accountability not only in formal terms, but also as informal and everyday talk and behaviour. Furthermore, I propose that the problems of implementation described above can be reframed instead as tensions between accountabilities. In this study therefore, I examine how clinicians negotiate multiple accountabilities in their practices of safety. With a multidisciplinary group of 72 clinicians in a children’s hospital in New South Wales, Australia, I created ethnographic data through observations, field interviews and feedback sessions in two phases of field work, over ten months in total. Following each phase, data were iteratively coded and analysed using a grounded theory approach. With these data, I show how clinicians are enacting safety through their practices of accountability, in contexts complicated by multiple accountabilities and multiple meanings of safety. I show how clinicians inevitably produce accounts that are partial and ‘incomplete’, at risk of becoming problematically disembedded from complexity. I also show how clinicians are re-embedding these partial accounts, by engaging in accountability practices that foreground multiplicity, diversity and reciprocity. I argue that if we wish for practices of accountability to reflect and support clinical practices that we see as complex and interconnected, then we need to embrace more complex and interconnecting practices of accountability. Rather than calling for more accountability, we need to practice more accountabilities instead, to increase the reciprocal and reflexive engagement of participants with one another in (and beyond) the health care system. In doing so, we would enable care that is ‘safer’ by enabling more people to participate more variously and directly in negotiating the complexity and shifting boundaries of health care delivery.
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