Managing risk and uncertainty: the organisational dynamics of early warning systems
Health Sciences University of Leicester United Kingdom,
New ways of governing health services have involved a narrative shift towards high-reliability organisations and utilisation of procedural standards to manage operational risks. Few studies in healthcare have described and theorised how procedural standards are actioned to manage operational risks arising from processes, people or systems. This paper suggests examining procedural standards as organisational accountability mechanisms that seek to define responsibilities in frontline risk management. Based on an ethnographic study of patient safety and ward culture in four UK hospitals that participated in the Health Foundation's Safer Patients Initiative, the paper examines early warning systems aimed at managing risks of patient deterioration on hospital wards. Observational data and interviews with nurses, doctors, and staff from patient safety and risk management were analysed to examine how organisational accountability is translated into frontline risk management.
Early warning systems were examined by constructing a conceptual framework based on theoretical and empirical work on risk, accountability and responsibility. The systems emerged as risk management strategies that introduce accountability relationships and mechanisms to activate those relationships. This involves delegating risk management responsibilities to professionals; associating organisational targets such as patient safety with good professional practice; and placing professionals in clinical governance, patient safety and risk management. Thus organisational risk management seeks greater responsiveness and accountability as defined by hybrid forms of professional-managerial power.
The findings implied that early warning systems clarified accountabilities and responsibilities by defining: the causal pathways between monitoring practices and appropriate response; tasking and role responsibilities; and standards of appropriate practice. The systems were also perceived as promoting capacity building and good professional performance. Despite efforts to achieve greater accountability for standard practices, early warning systems generated negotiation over perceptions of risk, causality, and accountability relationships. As a result, organisational actors adjusted formal definitions of appropriate practice, causal pathways of risk management procedures, accountability expectations, and allegiances to sources of authority. The paper will discuss hybrid organisational and professional accounts of risk, and how they influenced operationalisation of early warning systems. The paper will also discuss the qualities of the conceptual framework in analysing organisational approaches to risk and uncertainty.