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Changing Culture in Healthcare

Chiou, Howard (2015)
Dissertation (306 pages)
Committee Chair / Thesis Advisers: Konner, Melvin J; Brown, Peter J
Committee Members: Worthman, Carol ; Buchman, Timothy George
Research Fields: Anthropology, Medical and Forensic ; Anthropology, Cultural; Health Sciences, General
Keywords: Medical anthropology; Medical error; Teamwork; Collaborative care; Multidisciplinary rounds; Ethnography
Program: Laney Graduate School, Anthropology
Permanent url: http://pid.emory.edu/ark:/25593/r8hfn

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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