Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

'The way you talk, do I have a choice?' Patient narratives of medication decision-making during hospitalization

OBJECTIVE

Based on the principle of the autonomy of the patient, shared decision-making (SDM) is the ideal approach in clinical encounters. In SDM, patients and healthcare professionals (HCPs) share knowledge and power when faced with the task of making decisions. However, patients are often not involved in the decision-making process. In this study, we explore medication decision-making during hospitalization and how power in the specific patient-HCP relationship is articulated, as analysed by Foucauldian theory.

METHODS

A qualitative case study, comprising observations of patient-HCP encounters at an internal medicines ward at a university hospital in Norway, followed by semi-structured interviews. The narratives (n = 4 patients) were selected from a larger study (n = 15 patients). The rationale behind the choice of these patients was to include diverse and rich accounts. The four patients in their 40s-70s were included close to the day of presumed discharge.

RESULTS

The narratives provide an insight into the patients as persons, their perspectives, including what mattered to them during their hospitalization, especially in relation to medications. Overall, SDM was not observed in this study. Even though all the participants actively tried to keep their autonomous capacity and to resist the HCPs' use of power, they were not able to change the established dynamics. Moreover, they were not allowed an equal voice to those of HCPs and thus not to escape the system's objectification and subjectification of them.

CONCLUSION

There is a need for HCPs to get more familiarized with SDM. The healthcare system and the individual HCP need to make more room for dialogue with the patients about their preferences. A part of this is also how health care systems are structured and scheduled, thus, it is important to empower patients and HCPs alike.

Coding for quality? Accountability work in standardised cancer patient pathways (CPPs)

A vital part of standardised care pathways is the possibility to measure performance through different indicators - for example, codes. In this article, based on interviews with health personnel in a project evaluating the introduction of standardised cancer patient pathways (CPPs) in Norway, we explore the specific types of work involved when health personnel produce codes as (intended) signifiers of quality. All the types of work are dimensions of what we define as accountability work - work health personnel do to make the codes signifiers of quality of care in the CPP.Codes and coding practices raise questions of what quality of care represents and how it could and should be measured. Informants in our study advocate for coding as important work for the patient more than for 'the system'. This shows how organising for quality becomes a crucial part of professional work, expanding what it means to perform high quality care.

Factors that influence scope of practice of the five largest health care professions in Australia: a scoping review

INTRODUCTION

A well-functioning health system delivers quality services to all people when and where they need them. To help navigate the complex realm of patient care, it is essential that health care professions have a thorough understanding of their scope of practice. However, a lack of uniformity regarding scope of practice across the regulated health professions in Australia currently exists. This has led to ambiguity about what comprises scope of practice in some health care professions in the region.

OBJECTIVE

The objective of this review was to explore the literature on the factors that influence scope of practice of the five largest health care professions in Australia.

METHODS

This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the five largest health care professions in Australia. The search was conducted using the following databases: AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, EMBASE (Excerpta Medica Database), MANTIS (Manual, Alternative and Natural Therapy Index System), MEDLINE, PubMed, and SCOPUS. Additional data sources were searched from Google and ProQuest.

RESULTS

A total of 12 771 publications were identified from the literature search. Twenty-three documents fulfilled the inclusion criteria and were included in the final analysis. Eight factors were identified across three professions (nursing & midwifery, pharmacy and physiotherapy) that influenced scope of practice: education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structures, financial factors, and professional and personal factors.

CONCLUSION

The results of this study will inform a range of stakeholders including the private and public arms of the healthcare system, educators, employers, funding bodies, policymakers and practitioners about the factors that influence scope of practice of health professions in Australia.

Decentred regulation: The case of private healthcare in India

In order to progress towards more equitable social welfare systems we need an improved understanding of regulation in social sectors such as health and education. However, research to date has tended to focus on roles for governments and professions, overlooking the broader range of regulatory systems that emerge in contexts of market-based provisioning and partial state regulation. In this article we examine the regulation of private healthcare in India using an analytical approach informed by 'decentred' and 'regulatory capitalism' perspectives. We apply these ideas to qualitative data on private healthcare and its regulation in Maharashtra (review of press media, semi-structured interviews with 43 respondents, and three witness seminars), in order to describe the range of state and non-state actors involved in setting rules and norms in this context, whose interests are represented by these activities, and what problems arise. We show an eclectic set of regulatory systems in operation. Government and statutory councils do perform limited and sporadic regulatory roles, typically organised around legislation, licensing and inspections, and often prompted by the judicial arm of the state. But a range of industry-level actors, private organisations and public insurers are involved too, promoting their own interests in the sector via the offices of regulatory capitalism: accreditation companies, insurers, platform operators and consumer courts. Rules and norms are extensive but diffuse. These are produced not just through laws, licensing and professional codes of conduct, but also through industry influence over standards, practices and market organisation, and through individualised attempts to negotiate exceptions and redressal. Our findings demonstrate regulation in a marketised social sector to be partial, disjointed and decentred to multiple loci, actively representing differing interests. Greater understanding of the different actors and processes at play in such contexts can inform future progress towards universal systems for social welfare.

Exploration of prescribing error reporting across primary care: a qualitative study

OBJECTIVES

To explore barriers and facilitators to prescribing error reporting across primary care.

DESIGN

Qualitative semi-structured face-to-face and telephone interviews were conducted to explore facilitators and barriers to reporting prescribing errors. Data collection and thematic analysis were informed by the COM-B model of behaviour change. Framework analysis was used for coding and charting the data with the assistance of NVivo software (V.12). General and context specific influences on prescribing error reporting were mapped to constructs from the COM-B model (ie, capability, opportunity and motivation).

SETTING

Primary care organisations, including community pharmacy, general practice and community care from North East England.

PARTICIPANTS

We interviewed a maximal variation purposive sample of 25 participants, including prescribers, community pharmacists and key stakeholders with primary care or medicines safety roles at local, regional and national levels.

RESULTS

Our findings describe a range of factors that influence the capability, opportunity and motivation to report prescribing errors in primary care. Three key contextual factors are also highlighted that were found to underpin many of the behavioural influences on reporting in this setting: the nature of prescribing; heterogeneous priorities for error reporting across and within different primary care organisations; and the complex infrastructure of reporting and learning pathways across primary care. Findings suggest that there is a lack of consistency in how, when and by whom, prescribing errors are reported across primary care.

CONCLUSIONS

Further research is needed to identify cross-organisational and interprofessional consensus on agreed reporting thresholds and how best to facilitate a more collaborative approach to reporting and learning, that is, sensitive to the needs and priorities of disparate organisations across primary care. Despite acknowledged challenges, there may be potential for an increased role of community pharmacy in prescribing error reporting to support future learning.

Development and Effectiveness of a Patient Safety Education Program for Inpatients

Background: Patient safety is considered an important issue in the field of healthcare, and most advanced countries. Purpose: This study was designed to evaluate a patient safety education program among hospitalized patients. Of the 69 participants, 33 completed the patient safety education program while the 36 remaining participants were given educational booklets. The program was used to measure knowledge about patient safety, patient safety perception, and willingness to participate in patient safety. Methods: Patient safety education was developed by the analysis–design–development–implementation–evaluation model considering expert advice, patient needs, and an extensive literature review. Data were collected from 20 July to 13 November 2020. Data were analyzed using SPSS statistical program. The effectiveness of the experimental and control groups before and after education was analyzed using paired t-tests, and the difference in the amount of increase in the measured variables for each group was analyzed using independent t-tests. Results: The experimental group had significantly higher patient safety scores (t = 2.52, p = 0.014) and patient safety perception (t = 2.09, p = 0.040) than those of the control group. However, there was no significant difference between the two groups regarding the willingness to participate in patient safety. Conclusion: The patient safety education program developed using mobile tablet PCs could be an effective tool to enhance patient involvement in preventing events that may threaten the safety of patients. Further studies are recommended to develop a variety of educational interventions to increase patient safety knowledge and perceptions of patients and caregivers.

Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK

BACKGROUND

Fundamentally, the goal of health professional regulatory regimes is to ensure the highest quality of care to the public. Part of that task is to control what health professionals do, or their scope of practice. Ideally, this involves the application of evidence-based professional standards of practice to the tasks for which health professional have received training. There are different jurisdictional approaches to achieving these goals.

METHODS

Using a comparative case study approach and similar systems policy analysis design, we present and discuss four different regulatory approaches from the US, Canada, Australia and the UK. For each case, we highlight the jurisdictional differences in how these countries regulate health professional scopes of practice in the interest of the public. Our comparative Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis is based on archival research carried out by the authors wherein we describe the evolution of the institutional arrangements for form of regulatory approach, with specific reference to scope of practice.

RESULTS/CONCLUSIONS

Our comparative examination finds that the different regulatory approaches in these countries have emerged in response to similar challenges. In some cases, 'tasks' or 'activities' are the basis of regulation, whereas in other contexts protected 'titles' are regulated, and in some cases both. From our results and the jurisdiction-specific SWOT analyses, we have conceptualized a synthesized table of leading practices related to regulating scopes of practice mapped to specific regulatory principles. We discuss the implications for how these different approaches achieve positive outcomes for the public, but also for health professionals and the system more broadly in terms of workforce optimization.

Physician managers in Hong Kong public hospitals

PURPOSE

Examining the self-identification of physician managers with their manager and clinician roles, and its impact on the state and professional powers in healthcare governance.

DESIGN/METHODOLOGY/APPROACH

With purposive sampling, a total of 15 frontline clinical department managers (mainly principal consultants) and directorial managers (mainly Hospital Chief Executives) were recruited to elite interviews. The themes for data collection and analysis were based on a systematic scoping review of previous empirical studies.

FINDINGS

Physician managers maintained respective jurisdictions in policymaking and clinical governance, as well as their primary self-identification as rationalizers or protectors of medicine, according to their managerial roles at a directorial or departmental level. However, a two-way hybridization of physician managers allowed the exchange of clinical and managerial authority, resulting in cooperation alongside struggles among medical elites; while some frontline managers were exposed to managerial values with the awareness of budget and organizational administration, some directorial managers remained aligned to a traditional mode of professional communication, such as persuasion through informal personal networks and by using clinician language and maintaining symbolic contact with the clinical field.

ORIGINALITY/VALUE

This study identifies the inconsistency in physician managers' identity work, as well as its patterns. It goes beyond a dichotomized framework of professionalism versus managerialism or an arbitrarily blurred identity.

System Issues Leading to "Found-on-Floor" Incidents: A Multi-Incident Analysis

BACKGROUND

Although attention to patient safety issues in the home care setting is growing, few studies have highlighted health system-level concerns that contribute to patient safety incidents in the home. Found-on-floor (FOF) incidents are a key patient safety issue that is unique to the home care setting and highlights a number of opportunities for system-level improvements to drive enhanced patient safety.

METHODS

We completed a multi-incident analysis of FOF incidents documented in the electronic record system of a home health care agency in Toronto, Canada, for the course of 1 year between January 2012 and February 2013.

RESULTS

Length of stay (LOS) was identified as the cross-cutting theme, illustrating the following 3 key issues: (1) in the short LOS group, a lack of information continuity led to missed fall risk information by home care professionals; (2) in the medium LOS group, a lack of personal support worker/carer training in fall prevention led to inadequate fall prevention activity; and (3) in the long LOS group, a lack of accountability policy at a system level led to a lack of fall risk assessment follow-up.

CONCLUSIONS

Our study suggests that considering LOS in the home care sector helps expose key system-level issues enabling safety incidents such as FOF to occur. Our multi-incident analysis identified a number of opportunities for system-level changes that might improve fall prevention practice and reduce the likelihood of FOF incidents in the home. Specifically, investment in electronic health records that are functional across the continuum of care, further research and understanding of the training and skills of personal support workers, and enhanced incentives or more punitive approaches (depending on the circumstances) to ensure accountability in home safety will strengthen the home care sector and help prevent FOF incidents among older people.

Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature

OBJECTIVE

The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance.

DESIGN

Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement.

DATA SOURCES

We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020.

ELIGIBILITY CRITERIA

We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare.

DATA EXTRACTION AND SYNTHESIS

Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model.

RESULTS

The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism.

CONCLUSIONS

This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation

INTRODUCTION

National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet).

METHODS AND ANALYSIS

Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period.

ETHICS AND DISSEMINATION

The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial.

Patient safety in medical residency training: Balancing bravery and checklists

Distributing responsibility for patient safety between individual professionals and organisational systems is a pressing issue in contemporary healthcare. This article draws on Habermas' distinction between 'lifeworld' and 'system' to explore patient-safety culture in medical residency training. Sociological accounts of medical training have indicated that applying systemic solutions in patient-safety training and practice may conflict with residents' needs. Residents would navigate safety systems to get their work done and safeguard learning opportunities, acting 'in between' the system and traditional processes of socialisation and learning on the job. Our ethnographic study reveals how residents seek to connect system and professional-based learning, and do them together in situated manners that evolve in the course of medical training. We reveal three themes that closely align with the residents' developmental process of maturing during training and on the job to become 'real' physicians: (1) coming to grips with the job; (2) working around safety procedures; and (3) moving on to independence. A more explicit focus on learning to deal with uncertainty may enable residents to become more skilled in balancing safety systems.

Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom

In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.

Collegiality as political work: Professions in today’s world of organizations

Collegiality is frequently portrayed as an inherent characteristic of professions, associated with normative expectations autonomously determined and regulated among peers. However, in advanced modernity other modes of governance responding to societal expectations and increasing state reliance on professional expertise often appear in tension with conditions of collegiality. This article argues that collegiality is not an immutable and inherent characteristic of the governance of professional work and organizations; rather, it is the result of the ability of a profession to operationalize the normative, relational, and structural requirements of collegiality at work. This article builds on different streams of scholarship to present a dynamic approach to collegiality based on political work by professionals to protect, maintain, and reformulate collegiality as a core set of principles governing work. Productive resistance and co-production are explored for their contribution to collegiality in this context, enabling accommodation between professions and organizations to achieve collective objectives and serving as a vector of change and adaptation of professional work in contemporary organizations. Engagement in co-production influences the ability to materialize collegiality at work, just as the maintenance and transformation of collegiality will operate in a context where professions participate and negotiate compromises with others legitimate modes of governance. Our arguments build on recent studies and hypotheses concerning the interface of professions and organizations to reveal the political work that underlies the affirmation and re-affirmation of collegiality as a mode of governance of work based on resistance and co-production.

Financialising acute kidney injury: from the practices of care to the numbers of improvement

Although sociological studies of quality and safety have identified competing epistemologies in the attempt to measure and improve care, there are gaps in our understanding of how finance and accounting practices are being used to organise this field. This analysis draws on what others have elsewhere called 'financialisation' in order to explore the quantification of qualitatively complex care practices. We make our argument using ethnographic data of a quality improvement programme for acute kidney injury (AKI) in a publicly funded hospital in England. Our study is thus concerned with tracing the effects of financialisation in the emergence and assembly of AKI as an object of concern within the hospital. We describe three linked mechanisms through which this occurs: (1) representing and intervening in kidney care; (2) making caring practices count and (3) decision-making using kidney numbers. Together these stages transform care practices first into risks and then from risks into costs. We argue that this calculative process reinforces a separation between practice and organisational decision-making made on the basis of numbers. This elevates the status of numbers while diminishing the work of practitioners and managers. We conclude by signalling possible future avenues of research that can take up these processes.

Identifying and managing concerns about GPs in England: an interview study and case-series analysis

Background

Underperforming doctors have been the focus of sustained interest from the media, policymakers, and researchers. GPs are more likely to be the subject of a complaint than any other type of doctor in the UK, and the management of concerns in primary care needs improvement, yet more is known about how concerns are managed in secondary care.

Aim

Although formal policies for NHS England’s management of concerns are clear, little is known about how these are put into practice. This study explores how concerns are identified, investigated, and managed at a regional level.

Design and setting

A qualitative study of the management of concerns in primary care across eight area teams.

Method

The study comprised two main strands: in-depth interviews with NHS England staff; and the analysis of case file data.

Results

The process for raising concerns was identified as inconsistent and disparate, with potential weaknesses to address. The concerns process was flexible. A trade-off between adaptability and consistency was evident, but the correct balance of the two is difficult to establish. Performance concerns were most common, followed by behaviour. Conduct was the next most frequently raised concern, and a small number of health cases were identified. Outcomes of cases appeared to be dependent on the doctor’s engagement and response rather than necessarily the nature of a concern or the consequences of a doctor’s actions.

Conclusion

The way practices handle complaints and concerns remains unexamined, even though they are a key route for patient complaints.

Re-structuring the negotiated order of the hospital

Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on 'ordering' in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio-recorded, semi-structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in-patient hospital departments, the ED has limited legitimacy claims of organ-specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.

Physician compliance with quality and patient safety regulations: The role of perceived enforcement approaches and commitment

The implementation of a quality and patient safety accreditation system is crucial for hospitals. Although control systems-such as accreditation-can contribute to quality improvements, they also run the risk of unintended consequences. As a result, ways should be found to avoid or reduce these undesirable consequences. This study aims to answer this call by exploring the association of different approaches to the enforcement of rules (punishment, based on monitoring and threats of sanctions; and persuasion, based on dialog and suggestion) with compliance. To test the relation between perceived enforcement and compliance, this study used survey data collected from medical specialists (N = 92) of a large academic medical center. The findings indicate that the same system is interpreted differently and that only a perceived persuasion approach is related to higher levels of compliance. This effect is fully mediated by affective commitment. No direct or indirect effects on compliance were found for a perceived coercive approach. These results suggest that control systems can be perceived in different ways and that the implementation of a control system does therefore not automatically lead to negative and unintended outcomes.

New ways to get policy into practice

PURPOSE

Health service effectiveness continues to be limited by misaligned objectives between policy makers and frontline clinicians. While capturing the discretion workers inevitably exercise, the concept of "street-level bureaucracy" has tended to artificially separate policy makers and workers. The purpose of this paper is to understand the role of social-organizational context in aligning policy with practice.

DESIGN/METHODOLOGY/APPROACH

This mixed-method participatory study focuses on a locally developed tool to implement an Australia-wide strategy to engage and respond to mental health services for parents with mental illness. Researchers: completed 69 client file audits; administered 64 staff surveys; conducted 24 interviews and focus groups (64 participants) with staff and a consumer representative; and observed eight staff meetings, in an acute and sub-acute mental health unit. Data were analyzed using content analysis, thematic analysis and descriptive statistics.

FINDINGS

Based on successes and shortcomings of the implementation (assessment completed for only 30 percent of clients), a model of integration is presented, distinguishing "assimilist" from "externalist" positions. These depend on the degree to which, and how, the work environment affords clinicians the setting to coordinate efforts to take account of clients' personal and social needs. This was particularly so for allied health clinicians and nurses undertaking sub-acute rehabilitative-transitional work.

ORIGINALITY/VALUE

A new conceptualization of street-level bureaucracy is offered. Rather than as disconnected, it is a process of mutual influence among interdependent actors. This positioning can serve as a framework to evaluate how and under what circumstances discretion is appropriate, and to be supported by managers and policy makers to optimize client-defined needs.

Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine

Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such ‘hybrid’ doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation.

Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change.

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Responsible Officers are a new governance elite group in the UK medical profession.

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They work at the nexus of professional, managerial and regulatory spheres.

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Differ from other doctor-managers due to accountability for medical performance.

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Organisational context shapes experiences of this new role.

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Regulatory reform has engendered a new form of hybrid professionalism.

Between empowerment and self-discipline: Governing patients' conduct through technological self-care

Recent health policy renders patients increasingly responsible for managing their health via digital technology such as health apps and online patient platforms. This paper discusses underlying tensions between empowerment and self-discipline embodied in discourses of technological self-care. It presents findings from documentary analysis and interviews with key players in the English digital health context including policy makers, health designers and patient organisations. We show how discourses ascribe to patients an enterprising identity, which is inculcated with economic interests and engenders self-discipline. However, this reading does not capture all implications of technological self-care. A governmentality lens also shows that technological self-care opens up the potential for a de-centring of medical knowledge and its subsequent communalization. The paper contributes to Foucauldian healthcare scholarship by showing how technology could engender agential actions that operate at the margins of an enterprising discourse.

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Digital health policy in UK assumes an enterprising & empowered patient identity.

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Tensions between empowerment & discipline occur as patients self-care digitally.

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Digital health creates space for agential actions that improve communal health.

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A health-making agency operates in the margins of governmental self-care discourse.

Discursively framing physicians as leaders: Institutional work to reconfigure medical professionalism

Physicians are well-known for safeguarding medical professionalism by performing institutional work in their daily practices. However, this study shows how opinion-making physicians in strategic arenas (i.e. national professional bodies, conferences and high-impact journals) advocate to reform medical professionalism by discursively framing physicians as leaders. The aim of this article is to critically investigate the use of leadership discourse by these opinion-making physicians. By performing a discursive analysis of key documents produced in these strategic arenas and additional observations of national conferences, this article investigates how leadership discourse is used and to what purpose. The following key uses of medical leadership discourses were identified: (1) regaining the lead in medical professionalism, (2) disrupting 'old' professional values, and (3) constructing the 'modern' physician. The analysis reveals that physicians as 'leaders' are expected to become team-players that work across disciplinary and organizational boundaries to improve the quality and affordability of care. In comparison to management that is negatively associated with NPM reform, leadership discourse is linked to positive institutional change, such as decentralization and integration of care. Yet, it is unclear to what extent leadership discourses are actually incorporated on the work floor and to what effect. Future studies could therefore investigate the uptake of leadership discourses by rank and file physicians to investigate whether leadership discourses are used in restricting or empowering ways.

Medical revalidation as professional regulatory reform: Challenging the power of enforceable trust in the United Kingdom

For more than two decades, international healthcare crises and ensuing political debates have led to increasing professional governance and regulatory policy reform. Governance and policy reforms, commonly representing a shift from embodied trust in professionals to state enforceable trust, have challenged professional power and self-regulatory privileges. However, controversy remains as to whether such policies do actually shift the balance of power and what the resulting effects of policy introduction would be. This paper explores the roll-out and operationalisation of revalidation as medical regulatory reform within a United Kingdom National Health Service hospital from 2012 to 2013, and its impact upon professional power. Revalidation policy was subject to the existing governance and management structures of the organisation, resulting in the formal policy process being shaped at the local level. This paper explores how the disorganised nature of the organisation hindered rather than facilitated robust processes of professional governance and regulation, fostering formalistic rather than genuine professional engagement with the policy process. Formalistic engagement seemingly assisted the medical profession in retaining self-regulatory privileges whilst maintaining professional power over the policy process. The paper concludes by challenging the concept of state enforceable trust and the theorisation that professional groups are effectively regulated and controlled by means of national and organisational objectives, such as revalidation.

'Pastoral practices' for quality improvement in a Kenyan clinical network

We explain social and organisational processes influencing health professionals in a Kenyan clinical network to implement a form of quality improvement (QI) into clinical practice, using the concept of ‘pastoral practices’. Our qualitative empirical case study, conducted in 2015–16, shows the way practices constructing and linking local evidence-based guidelines and data collection processes provided a foundation for QI. Participation in these constructive practices gave network leaders pastoral status to then inscribe use of evidence and data into routine care, through championing, demonstrating, supporting and mentoring, with the support of a constellation of local champions. By arranging network meetings, in which the professional community discussed evidence, data, QI and professionalism, network leaders also facilitated the reconstruction of network members' collective professional identity. This consequently strengthened top-down and lateral accountability and inspection practices, disciplining evidence and audit-based QI in local hospitals. By explaining pastoral practices in this way and setting, we contribute to theory about governmentality in health care and extend Foucauldian analysis of QI, clinical networks and governance into low and middle income health care contexts.

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Pastoral practices influence health professionals to implement quality improvement.

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Local evidence-based guidelines and audit processes provide a foundation for QI.

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A constellation of network leaders and local champions inscribed QI into practice.

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Discussion in network meetings facilitated reconstruction of professional identity.

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Professionals disciplined their own use of evidence and audit for QI purposes.

The strategic defense of physician autonomy: State public health agencies as countervailing powers

Advances in genetic testing and the aggressive marketing of genetic tests by commercial diagnostic laboratories have driven both consumer demand and the need for unbiased information about how tests should guide healthcare delivery. This paper uses the countervailing powers framework to explore the role of state public health agencies as arbiters of quality and safety, specifically through their efforts to encourage physicians to follow evidence-based recommendations for screening for hereditary cancers. Social scientists have often viewed actions by the state to regulate cost, quality, or safety as a threat to physician autonomy. This paper draws on case studies from two US states-Michigan and Connecticut-to better understand the specific role of state public health agencies, and especially whether their activities to encourage adherence to evidence-based recommendations bolster or subvert the interests of other parties in the healthcare arena. We find that lacking authority to compel provider to follow evidence-based recommendations, they improvised ways to foster compliance voluntarily, for example, by emphasizing the role of the physician as gatekeeper, thus affirming the importance of physician autonomy and clinical judgment. Both states also used public health surveillance data to make rare diseases visible and illustrate gaps between recommendations and practice. Finally, they both showed that following evidence-based recommendations could align the professional and market interests of healthcare stakeholders. Both states employed similar strategies with similar effects, despite substantial differences in the regulatory climate and organizational capacity. Taken as a whole, their activities orchestrated a countervailing response that checked the profit-seeking motives of commercial laboratories. Our findings demonstrate that rather than eroding physician autonomy, state action to monitor healthcare quality and encourage adherence to evidence-based recommendations can actually reinforce physician authority.

Professional Talk: How Middle Managers Frame Care Workers as Professionals

This paper examines how middle managers in the long term care sector use the discourse of professionalism to create 'appropriate' work conduct of care workers. Using Watson's concept of professional talk, we study how managers in their daily work talk about professionalism of vocationally skilled care workers. Based on observations and recordings of mundane conversations by middle managers, we found four different professional talks that co-exist: (1) appropriate looks and conduct, (2) reflectivity about personal values and 'good' care, (3) methodical work methods, (4) competencies. Jointly, these professional talks constitute an important discursive resource for middle managers to facilitate change on the work floor. Change involves the reconfiguration of care work and different managerial-worker relations. Middle managers use professional talks in both enabling and disenabling ways vis-à-vis care workers. Based on these findings, we suggest a more nuanced portrayal of the relationship between managers and professionals. Rather than being based on an intrinsic opposition, i.e. 'managers versus professionals', this relationship is flexibly reconstructed via professional talk.

How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

CONTEXT

Incident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however,little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning.

METHODS

Our systematic literature review identified 2 groups of studies: (1)those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning.

FINDINGS

In total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures,and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set.

CONCLUSIONS

The results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and ledby clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs.

The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.

Healthcare quality and safety: a review of policy, practice and research

Over the last two decades healthcare quality and safety have risen to the fore of health policy and research. This has largely been informed by theoretical and empirical ideas found in the fields of ergonomics and human factors. These have enabled significant advances in our understanding and management of quality and safety. However, a parallel and at time neglected sociological literature on clinical quality and safety is presented as offering additional, complementary, and at times critical insights on the problems of quality and safety. This review explores the development and contributions of both the mainstream and more sociological approaches to safety. It shows that where mainstream approaches often focus on the influence of human and local environment factors in shaping quality, a sociological perspective can deepen knowledge of the wider social, cultural and political factors that contextualise the clinical micro-system. It suggests these different perspectives can easily complement one another, offering a more developed and layered understanding of quality and safety. It also suggests that the sociological literature can bring to light important questions about the limits of the more mainstream approaches and ask critical questions about the role of social inequality, power and control in the framing of quality and safety.

Enacting corporate governance of healthcare safety and quality: a dramaturgy of hospital boards in England

The governance of patient safety is a challenging concern for all health systems. Yet, while the role of executive boards receives increased scrutiny, the area remains theoretically and methodologically underdeveloped. Specifically, we lack a detailed understanding of the performative aspects at play: what board members say and do to discharge their accountabilities for patient safety. This article draws on qualitative data from overt non-participant observation of four NHS hospital Foundation Trust boards in England. Applying a dramaturgical framework to explore scripting, setting, staging and performance, we found important differences between case study sites in the performative dimensions of processing and interpretation of infection control data. We detail the practices associated with these differences--the legitimation of current performance, the querying of data classification, and the naming and shaming of executives--to consider their implications.

Institutions of care, moral proximity and demoralisation: The case of the emergency department

This article draws on concepts of morality and demoralisation to understand the problematic nature of relationships between staff and patients in public health services. The article uses data from a case study of a UK hospital Emergency Department to show how staff are tasked with the responsibility of treating and caring for patients, while at the same time their actions are shaped by the institutional concerns of accountability and resource management. The data extracts illustrate how such competing agendas create a tension for staff to manage and suggests that, as a consequence of this tension, staff participate in processes of 'effacement' that limit the presence of patients and families as a moral demand. The analysis from the Emergency Department case study suggests that demoralisation is an increasingly important lens through which to understand health-care institutions, where contemporary organisational cultures challenge the ethical quality of human interaction.

Chains of (dis)trust: exploring the underpinnings of knowledge-sharing and quality care across mental health services

Quality and safety in healthcare settings are underpinned by organisational cultures, which facilitate or impede the refinement, sharing and application of knowledge. Avoiding the use of the term culture as a residual category, we focus specifically on describing chains of (dis)trust, analysing their development across relatively low-trust service contexts and their impact upon knowledge-sharing and caregiving. Drawing upon data from in-depth interviews with service users, healthcare professionals, service managers and other stakeholders across three mental healthcare (psychosis) teams in southern England, we identify micro-mechanisms that explain how (dis)trust within one intra-organisational relationship impacts upon other relationships. Experiences and inferences of vulnerability, knowledge, uncertainty, interests and time, among actors who are both trustees and trusters across different relationships, are pertinent to such analyses. This more micro-level understanding facilitates detailed conceptualisations of trust chains as meso-level tendencies that contribute to wider vicious or virtuous cycles of organisational (dis)trust. We explore how knowledge-sharing and caregiving are vitally interwoven within these chains of trust or distrust, enhancing and/or inhibiting the instrumental and communicative aspects of quality healthcare as a result.

Public management 'reform' narratives and the changing organisation of primary care

This paper explores how different models of public management affect the changing organisation of primary care. It examines important non-clinical drivers of major organisational change. It uses the concept of a 'reform narrative' to connect public management reform ideas, political doctrines and their effects on primary care organisations. It outlines a set of possible models of public management and their application with primary care settings. It explores what might be the dominant reform ideas of the next decade.

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 Hood's 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.

Governing through community-based research: lessons from the Canadian HIV research sector

The "general public" and specific "communities" are increasingly being integrated into scientific decision-making. This shift emphasizes "scientific citizenship" and collaboration between interdisciplinary scientists, lay people, and multi-sector stakeholders (universities, healthcare, and government). The objective of this paper is to problematize these developments through a theoretically informed reading of empirical data that describes the consequences of bringing together actors in the Canadian HIV community-based research (CBR) movement. Drawing on Foucauldian "governmentality" the complex inner workings of the impetus to conduct collaborative research are explored. The analysis offered surfaces the ways in which a formalized approach to CBR, as promoted through state funding mechanisms, determines the structure and limits of engagement while simultaneously reinforcing the need for finer grained knowledge about marginalized communities. Here, discourses about risk merge with notions of "scientific citizenship" to implicate both researchers and communities in a process of governance.

Regulating healthcare complaints: a literature review

Purpose

– The purpose of this paper is to explore approaches to the regulation of healthcare complaints and disciplinary processes.

Design/methodology/approach

– A literature review was conducted across Medline, Sociological Abstracts, Web of Science, Google Scholar and the health, law and social sciences collections of Informit, using terms tapping both the complaints process and regulation generally.

Findings

– A total of 118 papers dealing with regulation of health complaints or disciplinary proceedings were located. The review reveals a shift away from self-regulation towards greater external oversight, including innovative regulatory approaches including “networked governance” and flexible or “responsive” regulation. It reports growing interest in adoption of strategic and responsive approaches to health complaints governance, by rejecting traditional legal forms in favor of more strategic and responsive forms, taking account of the complexity of adverse health events by tailoring responses to individual circumstances of complainants and their local environments.

Originality/value

– The challenge of how to collect and harness complaints data to improve the quality of healthcare at a systemic level warrants further research. Scope also exists for researching health complaints commissions and other “meta-regulatory” bodies to explore how to make these processes fairer and better able to meet the complex needs of complainants, health professionals, health services and society.

Lost in translation? 'Evidence' and the articulation of institutional logics in integrated care pathways: from positive to negative boundary object?

This article examines the translation of a clinical governance concept - integrated care pathways (ICPs)--into an infrastructural technology. Building on previous work, the application of boundary object theory is extended in this article to argue that stakeholder enrolment in pathway methodology may be less thoroughgoing than originally assumed. Pathways have effectively aligned management and nursing interests around a quality agenda and nurses have emerged as the leaders in this field, but doctors have rather lower levels of engagement. It is suggested that the contradictory logics inherent in pathway philosophy (primarily as these relate to 'evidence') and the social organisation of ICP development foster a transformation of the concept when this is translated into the technology, creating a negative boundary object from the perspective of doctors. Medicine is a powerful actor in health care, which is consequential for whether pathways, as designated boundary objects, become boundary objects-in-use. It also has implications for the diffusion of the concept as a mechanism of clinical governance and the credibility of nurses as emergent leaders in this field. Qualitative case studies of ICP development processes undertaken in the UK National Health Service and ethnographic research on the ICP community provide the empirical foundations for the analysis.

Between surveillance and subjectification: professionals and the governance of quality and patient safety in English hospitals

Two understandings of the dynamics of power developed by Foucault have been extensively used in analyses of contemporary healthcare: disciplinary power and governmentality. They are sometimes considered alternative or even contradictory conceptual frameworks. Here, we seek to deploy them as complementary ways of making sense of the complexities of healthcare organisation today. We focus on efforts to improve quality and safety in three UK hospitals. We find a prominent role for disciplinary power, including a panoptic gaze that is to some extent internalised by professionals. We suggest, however, that the role of disciplinary power relies for its impact on complementary strategies that are more akin to governmentality. These strategies foster organisational contexts that are receptive to disciplinary work. More fundamentally, we find that both disciplinary power and governmentality work on subjectivities in rather a different manner from that suggested by conventional accounts. We offer an alternative, less individualised and more socialised, understanding of the way in which power acts upon subjectivity and behaviour in professional contexts.

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

This paper reports on an exploratory study of intra-organisational knowledge brokers working within three large acute hospitals in the English National Health Services. Knowledge brokering is promoted as a strategy for supporting knowledge sharing and learning in healthcare, especially in the diffusion of research evidence into practice. Less attention has been given to brokers who support knowledge sharing and learning within healthcare organisations. With specific reference to the need for learning around patient safety, this paper focuses on the structural position and role of four types of intra-organisational brokers. Through ethnographic research it examines how variations in formal role, location and relationships shape how they share and support the use of knowledge across organisational and occupational boundaries. It suggests those occupying hybrid organisational roles, such as clinical-managers, are often best positioned to support knowledge sharing and learning because of their 'ambassadorial' type position and legitimacy to participate in multiple communities through dual-directed relationships.

Risk, governance and the experience of care

Drawing on perspectives from the governmentality literature and the sociology of risk, this article explores the strategies, tools and mechanisms for managing risk in acute hospital trusts in the United Kingdom. The article uses qualitative material from an ethnographic study of four acute hospital trusts undertaken between 2008 and 2010 focusing on the provision of dignified care for older people. Extracts from ethnographic material show how the organisational mechanisms that seek to manage risk shape the ways in which staff interact with and care for patients. The article bridges the gap between the sociological analysis of policy priorities, management strategy and the organisational cultures of the NHS, and the everyday interactions of care provision. In bringing together this ethnographic material with sociological debates on the regulation of healthcare, the article highlights the specific ways in which forms of governance shape how staff care for their patients challenging the possibility of providing dignified care for older people.

Who do we think we are? Analysing the content and form of identity work in the English National Health Service

PURPOSE

The language used by National Health Service (NHS) "commissioning" managers when discussing their roles and responsibilities can be seen as a manifestation of "identity work", defined as a process of identifying. This paper aims to offer a novel approach to analysing "identity work" by triangulation of multiple analytical methods, combining analysis of the content of text with analysis of its form.

DESIGN/METHODOLOGY/APPROACH

Fairclough's discourse analytic methodology is used as a framework. Following Fairclough, the authors use analytical methods associated with Halliday's systemic functional linguistics.

FINDINGS

While analysis of the content of interviews provides some information about NHS Commissioners' perceptions of their roles and responsibilities, analysis of the form of discourse that they use provides a more detailed and nuanced view. Overall, the authors found that commissioning managers have a higher level of certainty about what commissioning is not rather than what commissioning is; GP managers have a high level of certainty of their identity as a GP rather than as a manager; and both GP managers and non-GP managers oscillate between multiple identities depending on the different situations they are in.

ORIGINALITY/VALUE

This paper offers a novel approach to triangulation, based not on the usual comparison of multiple data sources, but rather based on the application of multiple analytical methods to a single source of data. This paper also shows the latent uncertainty about the nature of commissioning enterprise in the English NHS.

Analytical perspectives on performance-based management: an outline of theoretical assumptions in the existing literature

Performance-based management (PBM) has become a dominant form of governance in health care and there is a need for careful assessment of its function and effects. This article contains a cross-disciplinary literature synthesis of current studies of PBM. Literature was retrieved by database searches and categorized according to analytical differences and similarities concerning (1) purpose and (2) governance mechanism of PBM. The literature could be grouped into three approaches to the study of PBM, which we termed: the ‘functionalist’, the ‘interpretive’ and the ‘post-modern’ perspective. In the functionalist perspective, PBM is perceived as a management tool aimed at improving health care services by means of market-based mechanisms. In the interpretive perspective, the adoption of PBM is understood as consequence of institutional and individual agents striving for public legitimacy. In the post-modern perspective, PBM is analysed as a form of governance, which has become so ingrained in Western culture that health care professionals internalize and understand their own behaviour and goals according to the values expressed in these governance systems. The recognition of differences in analytical perspectives allows appreciation of otherwise implicit assumptions and potential implications of PBM. Reflections on such differences are important to ensure vigilant appropriation of shifting management tools in health quality governance.

Negotiating authority: a comparative study of reform in medical training regimes

Recently the medical profession has faced increased outside pressure to reform postgraduate medical training programs to better equip young doctors for changing health care needs and public expectations. In this article we explore the impact of reform on professional self-governance by conducting a comparative historical-institutional analysis of postgraduate medical training reform in the United Kingdom and the Netherlands. In both countries the medical training regime has shifted from professional self-regulation to coregulation. Yet there are notable differences in each country that cannot be explained solely by diverging institutional contexts. They also result from the strategic actions by the actors involved. Based on an assessment of the recent literature on institutional transformation, this article shows how strategic actions set negotiating authority processes into motion, producing new and sometimes surprising institutional arrangements that can have profound effects on the distribution and allocation of authority in the medical training regime. It stresses the need to study the interactions among political context, the properties of institutions, and negotiating authority processes, as they are crucially important to understanding institutional transformation.

The impact of management on medical professionalism: a review

In the last three decades, medical doctors have increasingly been exposed to management control measures. This phenomenon has been reflected in a number of studies in various disciplines, including sociology, organisation studies, management, and health service research. This article seeks to provide a comprehensive overview of the studies dealing with the impact of management on professional control. In particular, it seeks to bridge the diversity of assumptions, theoretical perspectives and conceptual underpinnings at play, by exploring synergies between them and opening up new horizons for research. The review shows how the relationship between clinicians and management has been analysed at an organisational level using two interconnected analytical frameworks focusing on the sociocultural and task-related dimensions of professionalism. In the final discussion, we argue that comparative, longitudinal and cross-sectional research is necessary, and there is a need to overcome the hegemony/resistance framework in current analyses of the impact of management on professionalism. Such an approach would contribute to the revision of macro theories of professionalism and stimulate emerging research by examining different perspectives towards management in medical specialisations. This approach might also stimulate a discussion of medical professionals' relationships with members of other professional groups, including nurses and healthcare managers.

Let's dance: Organization studies, medical sociology and health policy

This Special Issue of Social Science & Medicine investigates the potential for positive inter-disciplinary interaction, a 'generative dance', between organization studies (OS), and two of the journal's traditional disciplinary foundations: health policy and medical sociology. This is both necessary and timely because of the extent to which organizations have become a neglected topic within medical sociology and health policy analysis. We argue there is need for further and more sustained theoretical and conceptual synergy between OS, medical sociology and health policy, which provides, on the one-hand a cutting-edge and thought-provoking basis for the analysis of contemporary health reforms, and on the other hand, enables the development and elaboration of theory. We emphasize that sociologists and policy analysts in healthcare have been leading contributors to our understanding of organizations in modern society, that OS enhances our understanding of medical settings, and that organizations remain one of the most influential actors of our time. As a starting point to discussion, we outline the genealogy of OS and its application to healthcare settings. We then consider how medical sociology and health policy converge or diverge with the concerns of OS in the study of healthcare settings. Following this, we focus upon the material environment, specifically the position of business schools, which frames the generative dance between OS, medical sociology and health policy. This sets the context for introducing the thirteen articles that constitute the Special Issue of Social Science & Medicine.