Myles Leslie

What Counts? An Ethnographic Study of Infection Data Reported to a Patient Safety Program

CONTEXT Performance measures are increasingly widely used in health care and have an important role in quality. However, field studies of what organizations are doing when they collect and report performance measures are rare. An opportunity for such a study was presented by a patient safety program requiring intensive care units (ICUs) in England to submit monthly data on central venous catheter bloodstream infections (CVC-BSIs). METHODS We conducted an ethnographic study involving ∼855 hours of observational fieldwork and 93 interviews in 17 ICUs plus 29 telephone interviews. FINDINGS Variability was evident within and between ICUs in how they applied inclusion and exclusion criteria for the program, the data collection systems they established, practices in sending blood samples for analysis, microbiological support and laboratory techniques, and procedures for collecting and compiling data on possible infections. Those making decisions about what to report were not making decisions about the same things, nor were they making decisions in the same way. Rather than providing objective and clear criteria, the definitions for classifying infections used were seen as subjective, messy, and admitting the possibility of unfairness. Reported infection rates reflected localized interpretations rather than a standardized dataset across all ICUs. Variability arose not because of wily workers deliberately concealing, obscuring, or deceiving but because counting was as much a social practice as a technical practice. CONCLUSIONS Rather than objective measures of incidence, differences in reported infection rates may reflect, at least to some extent, underlying social practices in data collection and reporting and variations in clinical practice. The variability we identified was largely artless rather than artful: currently dominant assumptions of gaming as responses to performance measures do not properly account for how categories and classifications operate in the pragmatic conduct of health care. These findings have important implications for assumptions about what can be achieved in infection reduction and quality improvement strategies.

Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context

Abstract Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study’s multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study’s findings to other settings.

A qualitative study of speaking out about patient safety concerns in intensive care units.

Much policy focus has been afforded to the role of “whistleblowers” in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included “quiet words”, bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. But they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.

Policies supporting informal caregivers across Canada: A scoping review protocol

Introduction As the population ages, governments worldwide have begun seeking ways to support informal caregiving. In this light, Canada is no exception, but despite the centrality of the informal care strategy in elder care, we know little about the intertwining and overlapping policies that have been implemented to support informal caregivers providing assistance to the elderly, and to fellow citizens with disabilities. This review aims to identify the diversity of Canadian national, provincial and territorial policies supporting informal caregivers. It seeks, from its generalist focus on all informal care, to draw out specific observations and lessons for the elder care policy environment. Methods and analysis Given the vast and multidisciplinary nature of the literature on informal care policy, as well as the paucity of existing knowledge syntheses, we will adopt a scoping review methodology. We will follow the framework developed by Arksey and O’Malley that entails six stages, including: (1) identifying the research question(s); (2) searching for relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results; (6) and conducting consultation exercises. We will conduct these stages iteratively and reflexively, making adjustments and repetitions when appropriate to ensure we have covered the literature as comprehensively as possible. We will pursue an iterative integrated knowledge translation (iKT) strategy engaging our knowledge users through all stages of the review. Ethics and dissemination By adopting an iKT strategy we will ensure our knowledge users directly contribute to the project’s policy relevant publications. Upon completion of the review, we will present the findings at academic conferences, publishing a research report, along with an academic peer-reviewed article. Our intent is to develop an online, free-access evidence repository that catalogues the full range of Canada’s English language informal care support policies. Finally, the completed review will allow us to publish a series of policy briefs in collaboration with knowledge users illustrating how to promote and better implement informal care support policies. Our study has received ethics approval from the University of Calgary Conjoint Ethics Board.