Suzanne Grant

Contributions Of Ethnography To The Study Of Public Services Management

Abstract Ethnography in the study of public service organizations is gaining acceptance, but the practice of ethnography is changing in line with epistemological concerns and new organizational realities. We outline a move away from ethnography as participant observation of micro process in spatially bounded settings. Work in contemporary organizations is embedded in relationships that cross boundaries, and relationships are not just between people, but also between people and human artefacts such as IT systems. ‘Multi-sited’ ethnography is an approach to understand and manage ‘the organization’ as connections, disruptions and fluid boundaries. Implications for ethnographys contributions to multi-disciplinary organizational research are suggested.

Good practice statements on safe laboratory testing: A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

ABSTRACT Background: The systems-based management of laboratory test ordering and results handling is a known source of error in primary care settings worldwide. The consequences are wide-ranging for patients (e.g. avoidable harm or poor care experience), general practitioners (e.g. delayed clinical decision making and potential medico-legal implications) and the primary care organization (e.g. increased allocation of resources to problem-solve and dealing with complaints). Guidance is required to assist care teams to minimize associated risks and improve patient safety. Objective: To identify, develop and build expert consensus on ‘good practice’ guidance statements to inform the implementation of safe systems for ordering laboratory tests and managing results in European primary care settings. Methods: Mixed methods studies were undertaken in the UK and Ireland, and the findings were triangulated to develop ‘good practice’ statements. Expert consensus was then sought on the findings at the wider European level via a Delphi group meeting during 2013. Results: We based consensus on 10 safety domains and developed 77 related ‘good practice’ statements (≥ 80% agreement levels) judged to be essential to creating safety and minimizing risks in laboratory test ordering and subsequent results handling systems in international primary care. Conclusion: Guidance was developed for improving patient safety in this important area of primary care practice. We need to consider how this guidance can be made accessible to frontline care teams, utilized by clinical educators and improvement advisers, implemented by decision makers and evaluated to determine acceptability, feasibility and impacts on patient safety.

A meta-ethnography of organisational culture in primary care medical practice

PURPOSE Over the past decade, there has been growing international interest in shaping local organisational cultures in primary healthcare. However, the contextual relevance of extant culture assessment instruments to the primary care context has been questioned. The aim of this paper is to derive a new contextually appropriate understanding of the key dimensions of primary care medical practice organisational culture and their inter-relationship through a synthesis of published qualitative research. DESIGN/METHODOLOGY/APPROACH A systematic search of six electronic databases followed by a synthesis using techniques of meta-ethnography involving translation and re-interpretation. FINDINGS A total of 16 papers were included in the meta-ethnography from the UK, the USA, Canada, Australia and New Zealand that fell into two related groups: those focused on practice organisational characteristics and narratives of practice individuality; and those focused on sub-practice variation across professional, managerial and administrative lines. It was found that primary care organisational culture was characterised by four key dimensions, i.e. responsiveness, team hierarchy, care philosophy and communication. These dimensions are multi-level and inter-professional in nature, spanning both practice and sub-practice levels. RESEARCH LIMITATIONS/IMPLICATIONS The research contributes to organisational culture theory development. The four new cultural dimensions provide a synthesized conceptual framework for researchers to evaluate and understand primary care cultural and sub-cultural levels. PRACTICAL IMPLICATIONS The synthesised cultural dimensions present a framework for practitioners to understand and change organisational culture in primary care teams. ORIGINALITY/VALUE The research uses an innovative research methodology to synthesise the existing qualitative research and is one of the first to develop systematically a qualitative conceptual framing of primary care organisational culture.

Soft governance, restratification and the 2004 general medical services contract: the case of UK primary care organisations and general practice teams

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self-regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hoods four-part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer-based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer-led mutuality and externally led comptrol.

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

BackgroundThe handling of laboratory, imaging and other test results in UK general practice is a high-volume organisational routine that is both complex and high risk. Previous research in this area has focused on errors and harm, but a complementary approach is to better understand how safety is achieved in everyday practice. This paper ethnographically examines the role of informal dimensions of test results handling routines in the achievement of safety in UK general practice and how these findings can best be developed for wider application by policymakers and practitioners.MethodsNon-participant observation was conducted of high-volume organisational routines across eight UK general practices with diverse organisational characteristics. Sixty-two semi-structured interviews were also conducted with the key practice staff alongside the analysis of relevant documents.ResultsWhile formal results handling routines were described similarly across the eight study practices, the everyday structure of how the routine should be enacted in practice was informally understood. Results handling safety took a range of local forms depending on how different aspects of safety were prioritised, with practices varying in terms of how they balanced thoroughness (i.e. ensuring the high-quality management of results by the most appropriate clinician) and efficiency (i.e. timely management of results) depending on a range of factors (e.g. practice history, team composition). Each approach adopted created its own potential risks, with demands for thoroughness reducing productivity and demands for efficiency reducing handling quality. Irrespective of the practice-level approach adopted, staff also regularly varied what they did for individual patients depending on the specific context (e.g. type of result, patient circumstances).ConclusionsGeneral practices variably prioritised a legitimate range of results handling safety processes and outcomes, each with differing strengths and trade-offs. Future safety improvement interventions should focus on how to maximise practice-level knowledge and understanding of the range of context-specific approaches available and the safeties and risks inherent in each within the context of wider complex system conditions and interactions. This in turn has the potential to inform new kinds of proactive, contextually appropriate approaches to intervention development and implementation focusing on the enhanced deliberation of the safety of existing high-volume routines.

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care

Background Prescribing is a high-volume primary care routine where both speed and attention to detail are required. One approach to examining how organisations approach quality and safety in the face of high workloads is Hollnagel’s Efficiency and Thoroughness Trade-Off (ETTO). Hollnagel argues that safety is aligned with thoroughness and that a choice is required between efficiency and thoroughness as it is not usually possible to maximise both. This study aimed to ethnographically examine the efficiency and thoroughness trade-offs made by different UK general practices in the achievement of prescribing safety. Methods Non-participant observation was conducted of prescribing routines across eight purposively sampled UK general practices. Sixty-two semistructured interviews were also conducted with key practice staff alongside the analysis of relevant practice documents. Results The eight practices in this study adopted different context-specific approaches to safely handling prescription requests by variably prioritising speed of processing by receptionists (efficiency) or general practitioner (GP) clinical judgement (thoroughness). While it was not possible to maximise both at the same time, practices situated themselves at various points on an efficiency-thoroughness spectrum where one approach was prioritised at particular stages of the routine. Both approaches carried strengths and risks, with thoroughness-focused approaches considered safer but more challenging to implement in practice due to GP workload issues. Most practices adopting efficiency-focused approaches did so out of necessity as a result of their high workload due to their patient population (eg, older, socioeconomically deprived). Conclusions Hollnagel’s ETTO presents a useful way for healthcare organisations to optimise their own high-volume processes through reflection on where they currently prioritise efficiency and thoroughness, the stages that are particularly risky and improved ways of balancing competing priorities.

Beyond monitors: distributed situation awareness in anaesthesia management

ABSTRACT In this study, the construct and the role of distributed situation awareness (DSA) on the anaesthetic management of challenging major obstetric haemorrhage (MOH) cases is explored, specifically the anaesthetists perception of the operating theatre elements, the understanding of their meaning and the anticipation of their progress in interaction with other people and artefacts. Eighteen anaesthetists from four Scottish Hospitals were asked to discuss a challenging MOH case from their experience, prompted by questions emanating from a critical decision method protocol. The majority of the described DSA references were attributed to gathering information and in interaction with external artefacts, including monitors, suction containers, the whiteboard and even swabs. For understanding and anticipating, the majority of DSA references emerged in interaction with other team members within and outside the operating theatre. Methods for improving practice and training in MOH should address the interactive nature of DSA, by going beyond monitoring anaesthetic displays.

A meta-ethnography of the facilitators and barriers to successful implementation of patient complaints processes in health-care settings

To synthesize experiences of the patient complaints process for patients and health‐care professionals to identify facilitators and barriers in the successful implementation of patient complaints processes. This will assist the development of cultural change programmes, enabling complaints managers to incorporate stakeholder perspectives into future care.