Changing Culture in Healthcare Open Access
Chiou, Howard (2015)
Abstract
The medical community has increasingly focused on changing its culture. The reasons for this are two-fold-- first, culture is hypothesized as a significant driver of mortality from medical error. Second, the rising complexity of healthcare delivery has necessitated the shift from traditional models emphasizing the autonomy of individual practitioners towards interdisciplinary teams. Despite an intense focus on quality improvement, however, healthcare has proven resistant to change and knowledge of how to implement such changes remains extremely limited. The process of cultural change and its conceptualization needs to be better understood by both researchers in anthropology and the healthcare implementation sciences. Ethnographic tools are critical for capturing this complex process of social and cultural change within hospitals. Drawing on methods from both cultural anthropology and healthcare quality improvement, this manuscript is a multi-sited ethnography of inpatient hospital units implementing an intervention called the "Unit-Based Care Model." The UBCM was intended to facilitate teamwork between doctors and nurses--including bedside multidisciplinary rounds, safety checklists, and dyadic physician-nurse leadership. This ethnography builds comparative case studies of hospital units in the United States and Australia, drawing on data from participant observation, interviews, and quantitative safety culture questionnaires. The central investigation of this manuscript is one of a curious and unexpected paradox. While the UBCM successfully disrupted norms on one American unit, the intervention had little effect on existing hierarchies on the other. In contrast, the Australian units utilized a different implementation strategy altogether. Explaining this variation requires an understanding of hospital units as cultural systems, and the interactions between UBCM and its local context. Changing Culture in Healthcare illustrates the social and cultural nature of a complex change, and highlights a fundamental epistemological tension between the values of medicine as an evidence-based science, and medicine as an applied practice. This research further demonstrates the utility of the anthropological concepts of meaning and culture, and the clear need for translational social sciences to bridge anthropology and medicine.
Table of Contents
1: THE FATAL PARADOX OF CHANGE IN HEALTHCARE 1
PRIMUM NON NOCERE 1
THE RISE OF "PIT CREW" MEDICINE 4
THE CHALLENGE OF CULTURE IN MEDICINE 7
EXPERTS IN UNDERSTANDING CULTURE 12
THE EXPERIMENTAL UNIT 17
AN ANTHROPOLOGICAL MYSTERY 19
AN ANTHROPOLOGICAL APPROACH 22
CAPTURING INSIDERS 27
TRIANGULATING EVIDENCE 30
SENSITIZING CONCEPTS 35
AN OUTLINE 39
2: TRIBES IN THE HOSPITAL 43
LOUIS EVANS, MD 46
JUNIA MORGAN, RN 59
THE NEW GAME 83
3: THE INTERVENTION AND RITUAL 88
RITUALS IN THE HOSPITAL 89
THE EMIC 91
THE ROUNDS 94
THE ROUNDS, EXPLORED 97
THE UNIT-BASED CARE MODEL (UBCM) 112
IMPLEMENTATION ARTIFACTS AND RITUALS 115
THE ETIC 119
4: UNIT 2B 123
BEFORE THE IMPLEMENTATION 125
"THE FRIENDLIEST UNIT" 128
THE BOSS LADY 131
THE NURSES AND DOCTORS 135
THE DOCTORS AND NURSES 137
THE CCDT MEETING 139
PREPARATIONS 140
THE LAUNCH 145
AFTER THE ROUNDS 147
RISE OF THE TECHS 150
CONCLUSIONS 156
5: UNIT 3A 161
THE HARDEST FLOOR 164
THE UNIT CULTURE AT BASELINE 171
NURSING AS MENIAL 171
CONFLICTS WITH PATIENT-CENTERED CARE 174
PATIENTS AGAINST STAFF 178
A CULTURE OF WORKAROUNDS 181
THE FIRST IMPLEMENTATION 185
THE SECOND IMPLEMENTATION 189
AN AUTOPSY OF FAILURE 193
THE MUTATED MEANING OF CHECKLISTS 195
THE RECAPITULATION OF HIERARCHY 197
BMR AS DRAMATURGY 200
CONCLUSIONS 202
6: THE CHANGEMAKERS 206
DOWN UNDER 206
THE HEALTHCARE IMPROVEMENT COALITION 208
SIMILAR TECHNOLOGY, DIFFERENT CULTURE, SAME PROBLEMS 212
A SURPRISING HETEROGENEITY 215
ROYAL BOURKE HOSPITAL 215
OPALFIELDS HEALTH CAMPUS 216
NGAANYATJARRAKU BASE HOSPITAL 217
PACIFICA HOSPITAL 219
PURPLE MOUNTAINS MEDICAL CENTRE 220
A GLOBAL VIEW 223
EPISTEMOLOGICAL DIFFERENCES IN THE NATURE OF SUCCESS 227
7: CONCLUSIONS 232
WEBS OF COMPLEXITY 233
THE SOCIAL LIFE OF CHECKLISTS AND ROUNDS 237
RECOMMENDATIONS FOR HEALTHCARE LEADERS 240
RECOMMENDATIONS FOR ANTHROPOLOGISTS 243
RECOMMENDATIONS FOR THE IMPLEMENTATION SCIENCES 247
TOWARDS A TRANSLATIONAL SOCIAL SCIENCE 254
APPENDIX 1: QUANTITATIVE METHODOLOGY 258
BIBLIOGRAPHIC SOURCES 262
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