Ethnography in Healthcare Safety & Innovation?

I’m hoping the title doesn’t scare you away!  Grab a brew, [wo]man up & I’ll tell you why I believe this could be just the job as the NHS tries to understand & promote safer patient care.  I must have learned something during that sociology course at Med School.

If you’d asked me what ethnography meant just over a year ago… well, I would have struggled, truth be told.  The ethnography wiki is good, but it does not illustrate some points I wish to make about its potential in healthcare, especially for improving patient safety.

This, the formal definition “Ethnography |ɛθˈnɒgrəfi|noun [ mass noun ]the scientific description of peoples and cultures with their customs, habits,and mutual differences”.

A more helpful and illustrative definition is within the title of this publication, aimed more towards commercial applications & business innovation.

Last spring I was spending too many evenings soaking up Coursera offerings on ‘The Science of Healthcare Safety’  from the Armstrong Institute at Johns Hopkins, ‘Health Informatics in the Cloud’ from Georgia Tech and ‘Healthcare Innovation and Entrepreneurship’ from Duke.  Okay, I admit it –I’m a self-confessed MOOC junkie.  I’ve been trying to wean myself off lately, but I find this style of learning highly addictive.  If I was an academic, I would be very, very worried about what a disruptive innovation this is (I even took a MOOC on disruptive innovation in the autumn!).

‘The boy done good’ too I passed with distinction!  The more popular MOOCs do re-run, so be sure to checkout Coursera if you’d like to follow me down this path.  Other providers are available!

So, it was on that last one, innovation & Entrepreneurship that I first encountered the ethnography word.  The teachers were convincing in their assertions that healthcare entrepreneurs should grab a notepad and become a fly on the wall observing the processes, the workflows, the challenges, the frustrations, the good the bad and the ugly of modern healthcare. There they would see a better way, that gap in the market, unmask the unmet need crying out for innovation.  Whilst I like the National Geographic version of ethnography, this seemed to me a modern and highly practical way to deploy these skills.

So to healthcare safety. Never events are a complete misnomer.  At my trust we recently had a spate within one speciality, relating to one specific surgical procedure. When leaders at my trust discussed these sorry tales & we heard the stories behind them, it struck me that what I was hearing was that very similar errors were happening in series.  A new process had been brought in; standard operating procedures appeared not to have been significantly altered to accommodate to the change.  If there were theoretically 20 ways for things to go wrong, it looked like we were working through these error by error. Which one would be next?  Of course this is very easy to say in hindsight.  So, I got off that high horse and asked myself how can we find a better way.

And just like magic, Ethnography popped right into my head.

My brainwave was thinking that perhaps an appropriate response to serious untoward events/incidents is to get proactive ahead of the mandatory table-top review; for somebody to perform the magic of ethnography.  I thought, why base a root cause analysis on statements and opinions of the protagonists, who are going to be feeling highly defensive about their role in the medical error?  Trained observers could be deployed to document what they see & feel in a highly objective way, a way which would be impossible for those intimately involved.

In fact, if this idea was worth anything, why not apply it before errors happen, beginning in all the key areas covered by never events.

I was listening to BBC Radio 4’s ‘Thinking Allowed’ earlier, and blow me down if they weren’t discussing ethnography.  One of the issues Laurie Taylor and his guests raised is that ethnography is not what it used to be; maybe its best days are behind it.  The problems – it is time-consuming & it does not appeal to younger academics (since it does not yield to conventional academic research and publication timelines).  Most importantly, that means it does not easily attract funding in the UK.  Where, the presenters asked, might funding for future ethnographic studies come from?

I work in diabetes and endocrinology clinical care.  We encounter errors much more than we wish to.  Perhaps, with support from NHS England & from research bodies like NHIR a partnership could be forged between professional ethnographers, academic institutions and the NHS?  Key processes, workflows and Standard Operating Procedures could come under objective scrutiny.  This has the potential to direct us to that elusive better way, to see the unmet need, perhaps even to reveal a gap in the healthcare market which could ultimately increase revenue for the NHS and its partners.

It would be a privilege to help apply this approach to preventing serious untoward errors and incidents that affect the 1-in-10 people with diabetes that come into hospital each year. Look at the National diabetes inpatient audit and its reports.  They make alarming reading.

It is said that we must innovate our way out of the financial morass the NHS finds itself in.  Maybe ethnography could send us on our way.  What I don’t know is whether anyone is doing this in the NHS already. If not, perhaps it’s worth a go.  If they are, all power to them.  Pretty please, let’s partner up?