Surgical Patient Safety Officers in the United States: Negotiating Contradictions Between Compliance and Workplace Transformation

Abstract

A largely uncoordinated patient safety movement arose in response to the Institute of Medicine’s 1999 report on patient safety, To Err Is Human. Two key outcomes have resulted from that movement: (a) new guidelines that enlarge requirements for documenting compliance with patient safety data and (b) a new obligation for health care organizations to create a “safety culture” based on the “science” of safety. The organizational title patient safety officer (PSO) designates a member of an emerging occupation charged with assuming these enlarged responsibilities. This article seeks, first, to describe the emergence of this new organizational role, the PSO; second, to identify the new tensions that task and mission inflation have created for PSOs; and third, to examine how PSOs manage the tensions between their increased core work task and their new professional mission as agents of organizational change. Drawing on interviews conducted with 32 PSOs, 127 nurses, and 36 physicians in 17 surgical departments across 5 states in the United States from 2012 to 2015, the authors find that PSOs most commonly resolve the tension between core work activity and professional mission by focusing on their task as agents of audit and compliance. The authors find, as well, that when PSOs attempt to use their expanded role as social reformers to change behaviors in surgery, they must overcome the resistance of frontline workers. They require cooperation from executives and surgeons to effect change. When this support is unavailable, PSOs lose their voice and may abandon efforts to improve safety.

Keywords

professions medical sociology health policy qualitative research

Motivated by the Institute of Medicine’s To Err Is Human (Kohn et al., 2000), and its alarming claim that as many as 98,000 deaths a year in U.S. hospitals were the result of preventable adverse events, both federal and state agencies created new reporting requirements and imposed new organizational tasks to promote safer care. When the Affordable Care Act (2010) introduced a value-based payment program administered by the Centers for Medicare and Medicaid Services (CMS), hospitals were required to report selected quality measures to ensure full reimbursement (Gandhi, 2017; Thorpe, 2013).

The CMS has delegated accrediting responsibility for hospitals seeking reimbursement for services rendered to regulatory bodies such as the Joint Commission (Devers et al., 2004; Joint Commission, 2018), which now obliges health care providers to become “high reliability organizations” and urges executive leadership to create “a culture of safety” at their institutions. In addition, hospital and professional associations such as the American Hospital Association (Yokoe et al., 2014) and the American College of Surgeons initiated their own patient safety practices on top of the new reporting requirement.

Once regulation had imposed new obligations on health care organizations, those obligations precipitated organizational change (Bevan & Hood, 2006; McBarnet & Whelan, 1991). Studies of regulation suggest that professionals and organizational executives play a critical role in interpreting and representing patient safety performance measures (Heimer & Gazley, 2012; Pflueger, 2015), both to external auditors and to internal audiences. The necessary data collection is undertaken by existing, often expanding, departments of quality improvement or assurance, which may become offices of quality improvement. Data analysts who review clinical charts to extract data have become patient safety officers (PSOs). Although the name for their role varies across health care organization, PSOs typically carry out the same core task—data reporting—and have the same core mission: creating change that makes patient care safer. But when PSOs imagine their roles in the expansive way that patient safety advocates define them, a tension surfaces between their routine work and their mission to transform clinical practice. PSOs are tasked with the mundane clerical work of documenting an organization’s compliance with preexisting and newly imposed reporting requirements. At the same time, new rules governing safe behavior also charge PSOs with investigating critical incidents that require organizational scrutiny. This second task elevates their visibility and has the potential to enrich their authority in the organization.

The purpose of this article is, first, to describe the emergence of this new organizational role in surgical departments in the United States; second, to examine what tensions arise in this role; and third, to examine how PSOs manage tensions between their core work task and their greater professional mission. We compare and contrast PSOs’ core activity and mission as they interrelate at differently organized hospitals. Our data, collected from 2012 to 2015, come from interviews with 32 PSOs, 36 surgeons, and 127 nurses in 17 surgical departments located at rural and urban hospitals across the United States.

Our study is situated at the intersection of two lines of research. The first is scholarship on regulation and surveillance that discusses how professionals interpret and use regulatory standards in practice. We contribute to an understanding of how regulatory reform affects organizational structures and, conversely, how those structures influence the way that PSOs carry out their job. The second line of research is scholarship on emerging professions that explores how regulatory reform initiates behavioral change in professional groups. Our study brings into focus the contradictions these regulatory reforms create in health care organizational settings.

Theoretical Frameworks

Data, Transparency, and Accountability

Data reporting is seen as a mechanism to ensure organizational transparency and accountability (Reagan et al., 2016). The Centers for Disease Control and Prevention has developed the National Health Care Safety Network to measure quality. Quality measurement then determines the reimbursement rate paid when preventable adverse outcomes occur (Yokoe et al., 2014). The American College of Surgeons manages another surveillance system, the National Surgical Quality Improvement Program (NSQIP), that provides outcome measures that are adjusted for preoperative risk factors (Berenguer et al., 2010). However, the lack of standardization in the field of quality surveillance has created concerns among practitioners about duplication of efforts and lack of congruence among measures being used (Ju et al., 2015; Makary et al., 2013; Ramachandran & Kheterpal, 2011).

The need for hospitals and medical professionals to account for their practices and justify their intentions by reporting their performance measures arises out of changes in approaches to organizational governance (Power, 2000). Surveillance and reporting have become central operations in regulating social systems, especially when services involve public funds (Bevan & Hood, 2006; Power, 1999). For hospitals and physicians to demonstrate that new practices promote safer patient care, they must render clinical outcomes visible in a verifiable form (Power, 1999; Scott, 1998), collected in reports, submitted to regulatory bodies such as the CMS and the Joint Commission, or made available to consumers on publicly accessible websites.

Scholars of regulatory surveillance have demonstrated that the production of outcome measures is neither a neutral nor a straightforward process. Rather, interpreting outcomes depends on creative and often ritualistic acts on the part of those practitioners being audited (DiMaggio & Powell, 1991; Heimer & Gazley, 2012; Meyer & Rowan, 1977; Pflueger, 2015). How well performance measures, formal audits, or site visits by regulators describe an organization’s operation remains an open question (Power, 1999). This uncertainty has implications for occupational groups who must navigate between ceremonial and core functions within organizations (Sandholtz & Burrows, 2016).

Sociologists have commented both on the political dynamics of reforms in quality improvement and patient safety (Allen et al., 2016) and also on the importance of relational dynamics within organizations that structure the possibilities for safety reform interventions (Huising & Silbey, 2011; Szymczak, 2016). Decentralization and fragmentation of regulatory frameworks have placed the onus on organizations to interpret standards (Heimer & Gazley, 2012) and self-regulate their performance (Black, 2001). Compliance with regulatory reforms routinely produces tensions between the organization’s core mission and the goals embedded in the reform measures (Meyer & Rowan, 1977; Meyer & Zucker, 1989) that threaten organizational sustainability.

Ritualism emerges as one solution to managing competing institutional logics (Meyer & Rowan, 1977). Organizations use audits to send reassuring signals to regulatory bodies without actively changing the nature of their work (Power, 1999). Ritualism may exist when organizations set up structures such as safety committees that represent an intent to improve without actually changing practices in a meaningful way (Edelman et al., 2011).

Establishing ceremonial structures such as safety committees or units disconnected from the organization’s core mission poses challenges for occupations staffing these units (Edelman et al., 1991; Sandholtz & Burrows, 2016). Responsibility for integrating competing organizational logics often falls on staff who become “intrapreneurs” who attempt to reform organizations from within (Heinze & Weber, 2015). As middle managers, PSOs negotiate with those higher and lower in the health care organizational hierarchy to determine how standards and performance measures will be assessed and reported (Dobbin & Kelly, 2007; Huising & Silbey, 2011).

Context-specific understandings of how organizations and occupations interpret and adhere to standards are needed (Allen et al., 2016; Braithwaite & Braithwaite, 1995; Szymczak, 2016). In other words, entering the backstage to organizational practices (Heimer & Gazley, 2012) is necessary if we are to understand how occupations enact compliance with regulatory standards. Context-specific understandings of quality improvement reform are critical when viewed against the backdrop of extensive volatility and change in the health sector in the United States (Daudigeos, 2013; Fennell & Adams, 2011; Mendel & Scott, 2010; Mick & Shay, 2014). Cost containment strategies in the early 1990s led to a shift from managed care to a range of administrative models including the formation of networks that span community, state, and federal levels, the rise of for-profit health care organizations, and an increase in mergers between hospitals (Bazzoli et al., 2014; Caronna, 2011). These processes have exacerbated contradictions between cost containment and high-quality patient care (Reich, 2014). This study of the emergence of PSOs and their everyday work shows how variations in organizational cultures and structures set parameters for achieving patient safety (Greenwood et al., 2010; Kraatz & Block, 2008).

Patient Safety Workers

Health care regulatory reform stems from a theory of how to make patient care safer, and PSOs have the job of implementing this theory in practice. Their tasks are broadly linked to health care regulations (Birken et al., 2012; Gutberg & Berta, 2017; Parand et al., 2014; Zjadewicz et al., 2016). However, their roles are not limited to documenting compliance (Labelle & Rouleau, 2017). They are seen to play key roles in interpreting safety guidelines, expanding participation in safety projects, and building bridges among professional groups and departments involved in safety work.

PSOs fit Bucher and Strauss’s (1961) definition of emerging professional segments: “as loose amalgamations of segments pursuing different objectives in different manners and more or less delicately held together under a common name at a particular period in history” (p. 326). This perspective sees the medical profession as dynamic; change is the only constant (Goode, 1960, 1969; Hughes, 1971). “Movement is forced upon” professions, explain Bucher and Strauss (1961), “by changes in their conceptual and technical apparatus, in the institutional conditions of work, and in their relationship to other segments and occupations” (p. 332). For PSOs, regulatory change propelled their work mandate. Their location in the social space of the hospital makes them an ideal group to study for understanding how externally imposed regulatory frameworks shape work activities, mission, and internal relations among professional teams providing medical care.

Volatility in professional work has recently been explored in studies of how medical specialties claim core domains of expertise (Zetka, 2011) and secure recognition from colleagues and adjacent occupational groups (Fayard et al., 2017). A relational framework provides conceptual purchase on occupations that are not necessarily cohesive or dominant in relation to the umbrella professional group (Ramirez et al., 2015). An emerging professional group may possess “countervailing professional power” in a domain where groups “vie for resources, territory, and control to carry out their goals and vision of how health care should be” and can check the power of an otherwise dominant existing group of professional workers (Light, 1997, p. 107). The countervailing powers of PSOs are a tool for managing tensions between their mission and regular work activities. Focusing on correlated process of regulatory reform and change in professional occupations enables an understanding of how regulatory frameworks might propel professional change and also allows us to examine the contradictions that arise as a result of these reforms (Edelman et al., 1991; Heinze & Weber, 2015; Howard-Grenville, 2007).

For organizations to enact reform, professional staff need to perform “institutional work” (Braithwaite & Braithwaite, 1995; Lawrence et al., 2009, p. 215): The purposive action of individuals and organizations aimed at creating, maintaining, and reforming, or possibly even disrupting, standard organizational practice. This concept has been extended to study the practices that professional staff use to enact reform or disrupt existing work routines (Daudigeos, 2013; Heaphy, 2013; Howard-Grenville, 2007) by considering the tactics or schemas emerging professionals such as safety workers use to introduce and sustain safety regulation compliance in health care organizations.

Scholarship working at the intersections of occupations and law and society emphasizes the interdependence among and within occupational groups attempting to enact regulatory reform (Huising & Silbey, 2011). For work groups to accomplish their work role and occupational mission, they behave like “sociological citizens” (Silbey et al., 2009, p. 203): nonsociologists who have the capacity to see relational interdependence and use this systemic perspective to meet occupational and professional obligations.

Typically, the burden of organizational reform falls on peripheral or emerging professions operating in newly created departments (Edelman et al., 1991; Sandholtz & Burrows, 2016). Both the occupation and department are typically in marginalized positions that contribute to the ceremonial attention organizations pay to patient safety reform (DiBenigno, 2018b). Furthermore, introducing regulatory reforms is negotiated between lower and higher status professions (DiBenigno, 2018a; Howard-Grenville, 2007; Huising, 2015), which may create conflict and intergroup competition (DiBenigno, 2018b; Valentine, 2018).

Scholars of institutional reform suggest that enacting new regulations in organizations is considered to be “scut work” (Huising, 2015) or “dirty work” (Hughes, 1971) that may require an occupation to learn new tasks “unrelated to their specialized expertise, use understandings and work practices that conflict with their professional identity, or do impure or low-value tasks that threaten their professional interests” (Kellogg, 2014, p. 25). As a result of the perceived low value of regulatory reform work, lower status or emerging occupations tend to perform these tasks (Huising, 2015; Kellogg, 2014). In this article, we consider how PSOs leverage the scut work of patient safety compliance in surgical departments to accomplish their professional mandate.

Methods

In the course of acting as the ethnographic team in a 5-year national quality improvement and patient safety initiative funded by the Agency of Healthcare Research and Quality, we conducted 32 interviews with individuals who self-identified as having formal responsibility for patient safety in 17 surgical units spread across 5 states. In addition, we drew on interviews with 127 nurses and 36 surgeons to triangulate the perspectives of PSOs with the health care providers with whom they work most closely. The purpose of the quality improvement project was to introduce methods that would teach providers how (a) to organize practice to reduce surgical site infections and other complications of surgery and (b) to improve the culture of safety in surgery.

The project was based on a contract the Surgical Unit-Based Safety Program to Reduce Surgical Site Infections and Other Surgical Complications (HHSA29032001T-Task 5). The project was a collaboration between the University of Pennsylvania, Johns Hopkins University, the American College of Surgeons, and the Agency of Healthcare Research and Quality. It was an implementation science intervention. The Armstrong Institute for Patient Safety and Quality at Johns Hopkins University was responsible for delivering project content, engaging participating surgical units, and collecting and reporting outcome data. The American College of Surgeons assisted in collecting and analyzing data through the NSQIP database. The ethnographic research, undertaken by researchers from the University of Pennsylvania, was designed to provide immediate feedback to project implementers on how well or poorly participating hospitals were implementing the theory and method that were seen as essential to successful quality improvement.

Data Collection and Data Analysis

Hospitals participating in the national surgical safety project were recruited for this qualitative study. A combination of interviews and focus-group interviews were conducted; see Table 1 for a breakdown of the professional groups interviewed. Participating hospitals in the sample are diverse. They range in size from large academic hospitals to small remote hospitals; they are evenly split between for-profit and nonprofit status; and they vary in location from urban to rural settings. Table 2 provides hospital characteristics. A typical site visit consisted of a 1-to-5-day stay at each hospital, depending on the size of its operations. The researchers conducted observations in the operating room (OR), preoperative units, the postanesthesia care unit (PACU), and they observed surgical safety project meetings.

Table 1.

Hospital Personnel Interviewed.

Staff job type	Number
Nurses	127
Physicians	36
Patient safety officers	32
Technicians	26
Senior executives	12
Physician assistants	10
Administrators	7
Other surgical personnel	5
Total	255

Table 2.

Hospital Characteristics.

Characteristic	Total (N = 17)
Bed size
500–1,000	5
200–499	5
25–199	7
Region
Northeast	7
Southwest	5
West Coast	5
Rural or urban
Rural	4
Urban	13
Acute care	2
Community	9
Teaching	6
Financial (tax) status
For-profit	8
Nonprofit	9
Physician employment model
Hospital employed	3
Private/self-employed	14

Prior to each visit, the researchers liaised with members of the surgical safety project to arrange the site visit, and the on-site project participants in turn consulted with department managers, who discussed the study with their staff and invited them to participate in the study. Interviews were conducted with clinicians, administrators, and frontline staff. Given the work pressures placed on surgical staff, those who could afford to spare the time to be interviewed consented to the study. Repeat visits to 11 of the 17 studied hospitals were undertaken, enabling observations of change over time. The longitudinal dimension of this qualitative study provides evidence about how (if at all) surgical patient safety interventions interacted with staff’s attitudes toward error reporting and their work environment more broadly.

Ethical clearance for the qualitative study was secured through the University of Pennsylvania’s institutional review board. Oral consent procedures were followed at the start of individual and focus-group interviews. All interviews were digitally recorded, transcribed, anonymized, and uploaded to the qualitative software Dedoose for coding. The names of states, hospitals, and individuals were all removed from the transcribed interviews.

Using inductive analytic techniques (Corbin & Strauss, 2014), the research team developed a codebook for organizing the interview data. Then, having the definitions in the codebook, the researchers conducted first round of coding of all the interview and focus-group data. A team of research assistants recruited from work-study students at one of the participating universities assisted with the first round of coding. Coders were provided extensive training on the codebook and its definitions to ensure intercoder reliability (Kurasaki, 2000). Coders were then paired and coded the same interview to compare and contrast their interpretation of codes as a form of “negotiated agreement” to reconcile differences between coders (Campbell et al., 2013).Second round of coding used pattern coding strategies (Charmaz, 2006) to understand the relations between PSOs’ tasks, professional goals, and the challenges they face in executing their tasks and goals. The constant comparative method (Draucker et al., 2007) was used to contrast how diverse organizational characteristics, including hospital size and function, tax status, and physician employment models, structured PSOs’ roles and practices.

The credibility and confirmability of the research findings were ascertained through member checking (Lincoln & Guba, 1985). The research team disseminated field memos to participating hospitals summarizing its fieldwork findings. In addition, the research team participated in state coaching calls, and the findings of the study were shared with teams that participated, and those that did not, to provide a wider platform for feedback to verify our findings. Finally, our findings were shared with clinicians participating in the larger surgical safety project to confirm the qualitative researchers’ initial interpretations.

Results

Our findings are broken into three sections. The first section describes patient safety work, including PSOs’ work activities, their mission, and their career trajectories. The second section examines the tensions between PSOs’ work role and professional mission. The final section describes how PSOs attempt to manage these tensions to accomplish their professional mission.

Surgical Safety Work

PSOs manage their hospital’s patient safety programs. Higher level administrators hand over to them a broad portfolio of tasks and responsibilities that range from the solitary task of reviewing patient charts for gathering and presenting data that show compliance with formal regulations to the socially engaged task of planning and implementing programs so as to show improvement on safety targets.

Work Roles

The interrelated movements in health care, of evidence-based medicine and quality improvement, have brought into being a new specialized task—abstracting data from patient charts and displaying it in whatever format researchers or regulators demand. The PSOs we interviewed typically came into their position from the ranks of floor nurses already engaged in chart abstraction, and to this task the patient safety movement has added the role of organizational change agent. Many of the PSOs were connected with NSQIP, the data abstraction tool of the American College of Surgeons (2018).

Generating reports on hospital patient safety trends for national- and state-level administrative bodies forms a significant portion of PSOs’ work. This task is made more complicated by the fact that more than one administrative body needs documentation of compliance for incidents that require reporting, and administrative bodies have definitions of what needs to be reported—infections, for example (Ju et al., 2015; Makary & Daniel, 2016; Ramachandran & Kheterpal, 2011). By using data derived from chart abstraction to target particular areas of the hospital not meeting safety benchmarks, PSOs are able to engage clinicians directly, if only because quality is abstract whereas safety is tangible:

Quality has always been there, it’s just now more formalized, and moving kind of more into the 21st century having the information or data to prove what you’re trying to improve. You know, I think that’s the most important thing. For us, the way it looks, it has morphed over time again. Initially, quality was looked at as something a department did, which totally did not work. (Safety manager, Northeast hospital #1)

In this excerpt, the PSO directly links the formalization of patient safety to the introduction of quality improvement protocol surveillance mechanisms. Data surveillance and reporting gives PSOs a level of authority in the workplace:

Because I do the chart review, I see where the errors are. So, because the hospital itself only does the selection of the charts, they don’t see all of them, and I’m doing 40 charts a week and they’re doing 40 charts a month. So, I see more trends than they do. So, I can see like where their charting is going to get us in trouble. It hasn’t, but I think that’s because the corrective measures were put in place beforehand. (PSO, Northeast hospital #1)

PSOs’ roles are a composite of technical tasks related to data gathering and reporting and more abstract activities such as developing safety projects in the areas of vulnerability in patient care identified by the data reports they generate.

There are blurred lines between infection control and safety work, which often means that safety workers have a broad portfolio of tasks. One infection prevention officer in a large teaching hospital described the broad scope of her responsibilities: “the usual cleaning, disinfection, management of equipment, surveillance, reportable illnesses, and just about anything else that people don’t know what else to do with they call me” (PSO, Northeast hospital # 6). This description suggests how the breadth of tasks that PSOs and infection control officers perform often leaves them feeling overwhelmed.

Career Trajectory and Occupational History

As mentioned earlier, nursing was the dominant profession of origin for most PSOs (Table 3). Typically, they had spent several years or longer working as a floor nurse. Because this study focused on surgery, a large portion of PSOs interviewed had experience in surgery, although some officers gained experience in infectious disease, community nursing, or had spent time in the general wards.

Table 3.

Patient Safety Officers’ Demographic Characteristics.

Characteristic	Number (N = 32)
Professional background
Nurse	28
Pharmacy	1
Administration	3
Gender
Men	5
Women	27

The motivation for some PSOs in moving from floor nursing to quality improvement and patient safety was a desire to move into a management role. To their nursing degrees, many had added a degree in management and health administration to qualify for an organizational niche that began as quality improvement and then had patient safety added to the portfolio. PSOs who lacked formal credentialing expressed a commitment to patient safety while eschewing the need for formal credentialing:

I’ve been a nurse over 30 years and have kind of reinvented myself clinically and administratively in many different avenues throughout my career, but my most clinical area was the OR. I did actually work here back in the late 80s as a scrub and a circulator. Went on to go into an educator role and then ultimately management. I left the OR in the mid-90s to start my family. So, when I found that this position was available, it kind of … spoke to me. And I said, you know, quality—I’ve always had a passion for quality. I’ve always believed that at some levels, if you communicate it well, if you have a positive and an open communication style when you’re trying to make a delivery and when you’re uncovering things that could be very sensitive—practice is a very personal thing at a professional level—and I truly believe there’s a right way to do it if you intend to make traction. (NSQIP abstractor, Northeast hospital #2)

This excerpt highlights connections that PSOs often drew among their background in nursing, quality improvement, and their efficacy as communicators.

PSOs’ background as nurses was seen to be important for their ability to connect frontline staff to the hospital’s patient safety goals. Several officers explained their decision to move into this field as a result of their nursing experience:

Because both of us are seasoned nurses, we know what we’re looking at, as far as the process, patient care; that it makes a difference. You make rounds, they know who you are, you are supportive to the staff, no question is a stupid question, and sometimes just solving a little something will really make the difference for the patients’ outcome. (PSOs in a group interview, West Coast Hospital 1)

Many officers believed that, having begun their careers as nurses, they have greater credibility with frontline staff and are likely to be seen as supportive of staff and accessible to them. PSOs also drew on the values of nursing as the logic for their work: “Infection control has always been one of the things people looked at in different ways; we know from the days of Florence Nightingale that basic handwashing was emphasized” (PSO, Northeast hospital # 1).

Professional Mission

PSOs described their work in emotionally charged terms: “Campaigned. Kept saying, get, we have to do this, guys, we have to do this, guys. Nurse managers, push, push, push, push” (PSO, Northeast hospital # 5). They saw themselves as the champions of health care reform. While they invest a great deal personally in quality improvement, most PSOs emphasized that safety had to be an organization-wide commitment. When asked what they would like to accomplish in their role, the terms that PSOs most often used were buy-in, momentum, and sustainability. Thus, they defined their role as building connections within and between departments in the hospital, in a sense negotiating between professional groups—physicians, nurses, and senior management—and operating in the interstices between other occupational groups (Abbott, 1995; Huising & Silbey, 2011; Silbey et al., 2009).

PSOs highlighted their commitment to frontline staff as a priority in improving patient outcomes. They described a set of interpersonal processes—such as listening to staff’s concerns, encouraging nurses to speak up and report adverse events, encouraging honest feedback, and responding to that feedback accordingly—as being important to obtaining staff buy-in. Frequently PSOs described dismantling the hierarchy between surgeons and nurses as a professional goal:

Some of the operating rooms are starting to do things like introduce themselves, like I’m sure you’re well aware, but to the point where we’re actually coming down on a couple of surgeons whose hierarchical command of the OR is to be discouraged. Is that diplomatic enough? (Quality improvement officer and head of surgery in a joint interview, Northeast hospital #1)

Parallel to holding ambitious goals for reconfiguring social relations in the hospital, PSOs also used the language of implementation science—“science of safety,” “compliance with national safety measures,” and “data-driven reporting”—to characterize their work. For the officers, data persuade both external reviewers and frontline staff of the organization’s sincerity in its efforts to provide safer care and to measure changes in patient outcomes over time. If the end point is to change social and cultural practices in the hospital, then data-driven measures of safety are seen as the means to accomplish this vision:

I mean that is perhaps at the heart in a predominant kind of theory that we’re going after, that our frontline staff are more disengaged than ever before. They care deeply about patients and patient outcomes, but they don’t have the data to know about their own performance. (PSO, Northeast hospital #3)

Staff engagement in improving patient outcomes, in the view of this PSO, is directly tied to having access to data that measure hospital performance and presumably compliance with quality improvement guidelines.

Tensions in Accomplishing Work Role and Professional Mission

The surgical safety program was an attempt to bring to surgery an approach to error reduction that had been effective in intensive care units (ICUs). Many of our PSOs knew the principles of the program from its national implementation; their prior participation was a factor in having them enroll in the national surgical programs. Nevertheless, PSOs saw reducing surgical site infections as vastly more challenging than reducing them in ICUs:

The organizational structure of an operating room is much more complex than that of an intensive care unit. I think the staffing model for physicians in particular is fundamentally different in an OR than it is in a ICU, which I think makes physician engagement that much more challenging. The lack of the four walls in ICU and the staffing, I think makes it much harder. So, you know the way that the, you know, nursing staffs predominantly … oh so there are three stakeholders right there; there’s nursing, and often scrubs within nursing, there’s physician and then there’s anesthesia teams. (PSO, Northeast hospital #3)

This excerpt emphasizes the presence of discrete health professions as an obstacle to creating a cohesive safety program. Different stakeholders have divergent visions for improving safety that produce competing priorities and, ultimately, inertia. PSOs identified the rules that applied to surgeons and anesthesiologists as being different from those applied to nurses and technicians. Surgeons were perceived not to be as accountable to safety protocols as other health professionals.

PSOs saw professional competition and hierarchy as detrimental to quality improvement. Their mission then was an ambitious one: to reorient social relations from hierarchical to egalitarian forms of interaction. This necessitated PSOs being champions for both patients and frontline staff:

I would describe the culture, it’s a very me-me-me, protect myself. I think people are very closed off. I think we’re very, you know, in almost a self-preservation mode. I don’t feel that we work well between departments. I don’t feel that we work well, you know, even anesthesia to nursing. Now there are exceptions to the rule. There are some very good nurses. We have some very good anesthesiologists and some very good surgeons, but the majority, I don’t feel that we’re very team-oriented. You know, being in same day surgery, I feel like it’s a dumping ground kind of. You know, patients are coming directly out of the OR. Patients are coming out of PACU. If you try to stand up sometimes for yourself and me trying to stand up for my staff as a manager, there’s no one to support me to say, you know what? She’s right. She doesn’t have the staff to do that. You need to, common courtesy. We have no communication. (PSO, Northeast hospital #3)

Here, a middle manager wanting to stand up for staff to improve the overall quality of care places a strain on the manager’s professional authority, as PSOs have limited capacity to influence staff action. PSOs envisage a symbiotic relation among data, regulatory compliance, and clinical practice, with each one reinforcing the others. They are disappointed when data that speaks for itself as well as speaks for them says nothing to those who need to hear it.

Gathering Data From Critical Incident Reports

PSOs are tasked with transforming a punitive and personal approach to error into one that views error charitably and distributes responsibility widely. Patient safety measures encourage voluntary “nonpunitive” reporting of errors (Karlsen et al., 2009) designed to encourage frontline staff to report error (Pfeiffer et al., 2010). PSOs tend to be at the forefront in promoting accountability models and protecting staff who come forward with reports of error:

I was thinking about the adverse event reports, how that really, you know, I personally feel we turned everything around cause now my adverse event reports have quadrupled, but it also means that people are taking seriously the need to document any potential injury, things that they may have let go in the past. (Quality improvement group discussion, Northeast hospital #2)

In practice, however, PSOs we interviewed detected reluctance from frontline staff to participating in quality improvement and patient safety projects because of the added labor they involve, including participating in calls with national project staff, participating in local project team meetings, implementing the intervention in preoperative, OR, and PACU operations, and reporting their data to the national program team:

This is a downside of the project—is that you’re already getting so many negatives from people around saying, “Oh, no. You’re doing that? Why don’t you do real patient care? Why are you doing this and that?” And that’s what you hear over and over to the point where you just get frustrated and say, “Okay. Just put me in a room and I’ll just do regular work.” But that’s not where the passion is if you’re taking on the project the way you need to be taking it on. (PSO, Southwest hospital #1)

PSOs remain close to their nursing roots. Many PSOs voiced a strong desire to use patient safety initiatives to empower nurses, but the previous excerpt shows how safety projects could ignite staff resistance.

PSOs reported observing a high degree of mistrust and fear of reprisal on the frontline. Several PSOs said nurses perceived them as being police or auditors:

Nursing really was the only position that continually did the handwashing—the foaming in and foaming out—so that was just an observation and I didn’t say anything. Then we did a big campaign and we warned everyone that we were going to be observing handwashing in and out. We kept emphasizing in and out and that was a little more confrontational because when I asked you, “Excuse me. I notice you didn’t foam out or in.” I did get some interesting answers. (PSO, Northeast hospital #4)

This excerpt highlights the contradictions in a PSO’s roles. They have authority over physicians and nurses through their surveillance work, which grants them the power to document a physician or nurse’s noncompliance with safety protocols. However, using this power sows suspicion and mistrust. Mistrust erodes PSOs’ broader goals of empowering clinical staff to have a voice in patient safety: “More often than not, people look at us as being the police, and it’s so far from the truth that we’re more so there to help them than anything else” (PSO, Northeast hospital #5)

The position of the PSO within the hospital hierarchy varies by organization size. Large acute-care hospitals in our study sample employ 8 to 12 people performing safety roles, while small community hospitals might employ a single officer. PSOs are typically located in a quality improvement department. In hospitals where this department is centrally organized, PSOs reports directly to their administrative manager; in hospitals where PSOs are based in the clinical service lines, they report either to the nurse manager or to a physician. In hospitals where PSOs are based instead in surgical departments, they typically report to the chief of surgery. Several hospitals combined quality improvement and infection control into one department, and safety roles were distributed among both PSOs and infection control personnel. The lack of consistency in the PSO’s location and role in the hospital reflects the diverse practices that fall within the ambit of improvement (Zuiderent-Jerak & Berg, 2010) and the emergent nature of this new occupational specialty.

Frontline Staff’s Perspectives on Safety Reforms

For their part, frontline staff including nurses, surgeons, and technicians were generally supportive of new safety protocols. They saw the importance of these guidelines and felt passionate about improving the quality of patient care, as described by a nurse anesthetist:

The other day one of the nurses go, “Listen, I’m gonna call a stop.” And everybody stops and listens to what she has to say and if it gets, if it’s significant enough, then we call whoever’s the nurse management in to take a look at what’s going on right then and there. I’ve seen that happen twice here in a short period of time. I really was very impressed. (CRNA, Northeast hospital #4)

The nurse described in this quotation felt empowered to order a surgeon to stop the procedure momentarily to address a safety concern. These communicative practices are recommended in the Surgical Care Improvement Project developed by the Joint Commission (Stulberg et al., 2010) and in turn championed by PSOs.

Similarly, surgeons recognized how patient safety reforms strengthen clinical practice:

But I like to see, I mean, as more and more people have become aware of this—for instance, I know once I was involved with this, I sort of, I’m watching more closely in terms of what’s happening with the instruments and then hopefully over time, it’s not just me, it’s the techs, it’s the nurses, everyone is basically saying, hey, that, you know, that’s dirty. Let’s keep that out of the way. (Surgeon, Northeast hospital #1)

While there was general agreement among frontline staff that introducing safety reforms was positive, both nurses and surgeons were concerned about the growing reporting requirements attached to patient safety reform. PSOs gather composite data on critical incidents, errors, or “near misses”: unplanned events that might have led to error from the frontline. Error reporting procedures are context specific, but this nurse manager’s description of the error reporting process reflects common procedures we uncovered in our study:

Normally the nurse that finds it will write it. Sometimes if the nurse that committed the error did it and she happens to be there, someone will point it out and they’ll write it. An event report. From the event report, then it will go to the manager and the manager will do their, their investigation and kind of see what happened. And then, um, she’ll do counselling with the nurse or whoever it is and then when she’s done that, then it goes to quality. If it’s a big event type of thing it would be reported to quality right away. But we’d still go through the steps and quality would decide whether we would need to do a root cause analysis. (Nurse manager, West Coast Hospital 1)

The onus typically falls on frontline staff to submit written reports. Nurse managers are directly responsible for dealing with error reports and addressing the issue with their staff; quality improvement departments are apprised of the problem and become directly involved if the error is severe.

For nurses, error reporting entails a slew of personal and professional risks. Nurses prefaced their concerns about error reporting in relation to historical precedent. They referred to nurses being fired in the past for committing error. Or they spoke of having personally experienced disciplinary procedures by human resources that were then logged in their personnel file. In spite of assurances from PSOs and managers that there would be no negative repercussions for error reporting, many nurses expressed reservations about having to report problems in writing:

Even if it’s something that wasn’t necessarily your mistake, it was just a mistake. And then having to fill out a variance report and tell on yourself for it. (short laugh) It does, it feels, it feels a little … . And I’m skeptical about filling out event reports, and one of the reasons is in this state, this is discoverable evidence … . If for some reason, you put something in here, and it ends up going to court, the attorneys can subpoena that information. It’s like, it’s not protected. So I think when you put something in there, you’ve gotta be very careful about, you know, what you’re saying and how you’re wording it. So you know, do it with caution for sure. Yeah. (Nurse, Southwest hospital #1)

This passage reflects a common concern among nurses. There is a great deal of ambiguity in hospital policies about how error reports are managed, and they are uncertain about the potential repercussions for staff involved in the incident. In the aforementioned excerpt, the nurse is also concerned about whether written records might be used in litigation in the case of severe incidents.

The fear of repercussions from critical incident reporting for frontline staff varies both by organization and within organizations by surgeon. Nurses also expressed worry about the immediate consequences of error reporting both in relation to their work performance and their relationships with their coworkers and superiors:

Nurse: I’m assuming that it probably gets, it’s in your file, and it’s in HR or whatever, but I don’t know. Yeah. I don’t know the whole process and I don’t know how many write-ups you get before you get fired and you know, but I have seen employees here get fired, so it does scare me a little. It’s one small example but you hear a physician talk about “I was written up” and that impacts, it’s not the nurse individually but it’s the culture you know when they hear about other people getting, quote “written up.”

Interviewer: Oh the nurses getting written up?

Nurse: Or the nurses, or the physicians, or the disciplines.

Interviewer: Are they worried about . . .

Nurse: Themselves, yeah.

Interviewer: Well or retribution from writing somebody else up.

Nurse: Absolutely, absolutely.

Interviewer: So it’s not an anonymous system or is this just a small world?

Nurse: Um, you know it can be both, but at some point, you know if I report you as a surgeon that didn’t wash your hands going into Room A, you know there’s not too many choices around. (Nurse, West Coast Hospital 2)

Staff’s concerns are not only focused on the formal repercussions of error reporting but also its impact on work relations. Staff fear retaliation from their coworkers and are especially concerned about reporting errors that surgeons commit.

Surgeons, for their part, also expressed worry about retribution from frontline nursing staff and about the repercussions from having errors attributed to their surgical line:

And when you ask, well, what is retribution? From a physician point of view, retribution is getting poor, getting not the right people in my room, getting later start times. Just general passive-aggressive behavior towards you to the fact that referral patterns switch, your salary, I mean, it’s a whole spectrum of things. Your professional development as far as academics gets stifled. There’s, that’s the, and I’ve been here 11 years, it’s changing, but slowly, and that’s, people have, the institution or people who’ve been here have the institutional memory with them. (Surgeon, Southwest hospital #2)

Similar to nurses, surgeons worry about the informal forms of retribution they may incite if they report error or near misses.

Surgeons were also concerned about how data on hospital readmissions and NSQIP benchmarks for surgical site infections would impact their reputations:

That’s one of the frustrating things is we have all, you know, I think if you had talked amongst the surgeons, all of these Surgical Care Improvement Project things that you have to do and if you get, you get dinged if you fall out for a minute for the antibiotics, but none of it has really helped. (Surgeon, Northeast hospital #5)

Staff experience “program fatigue” because multiple new initiatives occur simultaneously. This surgeon is concerned about the repercussions of adverse event reporting on surgical reputation.

Critical incident reporting as an indicator of hospital regulatory compliance exposes health professionals both to formal censure and to informal workplace retribution. PSOs, for their part, are placed in contradictory positions, which make their assurances to insulate staff from retribution in many circumstances neither credible nor tenable.

Resources and Organizational Instability

Frontline staff and PSOs frequently discussed the detrimental impact that resource constraints and volatility in their work environment have on safety work. PSOs in small community and larger acute-care and teaching hospitals described their occupational mission differently. Smaller hospitals focused on compliance with national and safety standards. Several employees of these hospitals indicated that their hospitals were overwhelmed by audits:

Too routine and then we sometimes make it even harder because we’re constantly doing audits and going back and saying, “I know you say you’re doing it, but only 40% of the time we’re seeing it.” And it just becomes really hard. People get frustrated. (PSO, Southwest hospital #3)

PSOs in the larger hospitals tended to be more ambitious about quality improvements in their hospitals; for example, this PSO shared an impassioned vision for outcomes:

I would like to see a year down the line is that the staff understands the principles of the science of safety. They can speak to them and better yet, employ them every day. This is part of how we do things around here. If you can talk about things that you see that may not be best practice or might be putting the patient at risk and when you talk about it, folks react to it in a positive way and try to fix it, how could it not help? Yeah, rhetorical. I get passionate. I’m sorry. (PSO, Northeast hospital #6)

The priority for this PSO is training staff on the surgical safety project’s “science of safety” approach.

Differences in outlook for PSOs working for community hospitals and those working for larger teaching and acute-care hospital are likely a result of the financial constraints and staffing shortages at many community hospitals. Focusing on compliance with national and state regulations is a top priority when funding is scarce because with compliance comes increased funding; yet as the aforementioned extract from an interview with an officer at a rural community hospital suggests, staff are often overwhelmed by the auditing requirements and frustrated that their efforts to comply with safety standards have gained so little traction.

An additional obstacle that PSOs discussed in their interviews was the broader impact of organizational instability on sustaining quality improvement efforts. Several of the hospitals were preparing to merge with other hospitals, and the forthcoming merger had stalled safety efforts as the hospitals attempted to align their safety guidelines and procedures. Financial instability among community hospitals was a serious problem, and some of these hospitals had experienced layoffs or were facing the threat of staff layoffs. Safety initiatives had stalled as staff were stretched thin by taking on additional responsibilities, and fear had grown of losing their jobs if they acted as whistleblowers. Finally, changes in leadership had an equally unsettling impact on PSOs’ roles, as new leaders reoriented the organization’s priorities and as patient safety agendas changed in their wake.

Negotiating Work Activities and Occupational Mission

The Surgical Unit Safety Project developed a tool kit and recommended a set of practices to promote patient safety in surgery. The project was premised on applying concepts developed from prior implementation science studies (Dixon-Woods et al., 2011). Hospitals participating in the surgery safety project were encouraged to address easy problems that would create enough momentum to tackle more intractable problems later on (Gorbenko et al., 2015). The quality improvement department typically coordinated with a surgical safety committee comprising frontline staff and senior management who identified possible problems in surgery and introduced safety projects to remedy them. Examples of early successful projects included reducing traffic in the OR, introducing patient education programs to ensure greater patient preparedness for surgery, setting up suggestion boxes, and introducing postoperative briefings.

Intractable issues such as surgical complications place PSOs in positions where they need to confront professional hierarchy and competition within surgical departments to initiate change. PSOs use two broad strategies: The first is requiring greater levels of reporting on safety measures from frontline staff, and the second is initiating social reforms in surgical departments to address hierarchy and competition.

Surveillance and Compliance Work Activities

PSOs were enthusiastic about the efficacy of the new data reporting systems they had introduced, creating a feedback loop between data gathering and changes to clinical practice:

One of the first things we saw was acute renal failure with NSQIP and when we did a drill down of our data, we saw that a higher percentage of the cases were actually the colostomies. So, we adopted another NSQIP best practice guidelines that were shared at an annual conference. As a collaborative team we looked at the cases and we came up, we adopted the guidelines that were shared at the annual conference from another NSQIP hospital and it was just pre-hydration orders for patients that had bowel preps, also better pre-op education to those patients. We changed our order sets and the practice, we brought those cases in earlier in the day, you know, a little bit earlier than the regular time, like a half hour, so that we would get lytes, some labs, pre-op, and give time to pre-hydrate them based on what their comorbidities were. (PSO, Northeast hospital #6)

In this example, NSQIP data had revealed higher rates of renal failure, which surgeons attributed to a problem with patient preparedness and hydration; armed with these data, the patient safety team altered the daily schedule of surgery practices and strengthened patient education.

PSOs also described using data reporting as a means of enforcing compliance by physicians:

I mean, I did [with surgeons] before with this one surgeon who was pushing back on our safety policies. I said that, we’ll do it. We’ll formally carve you out [in data reports]. And then in 6 months, we’ll present your data compared to all the other surgeons and if you’re prepared to compare, if you’re so sure that what you’re doing here that you want to be off, away from the crowd, doing, we’ve got the resources now to look at every one of your cases and then we’ll present it to the entire department, not de-identified. This is Dr. X’s data. This is the rest of the department’s. If you’re so sure that you’re right, you want to do that, let’s do it. (PSO and chief of surgery in a group discussion, Northeast hospital #6)

Surgeons often have operating privileges in multiple community hospitals within a region. If surgeons are annoyed with the changes in practice compelled by a safety initiative that one hospital imposes, they can redistribute their patients to nearby hospitals. Even in large teaching hospitals in which surgeons are salaried employees, surgeons feel free to evaluate scientific evidence before adopting changes. Data reporting that compares surgical infection rates becomes an informal mechanism to control surgeons’ practices.

Frontline staff, in contrast, are employed by the hospital; thus, PSOs’ surveillance of staff’s safety practices, such as sustained handwashing, can be directly linked to staff performance assessments. Data demonstrate to state and federal regulators a hospital’s positive intentions to improve the quality of care, and data are used as a form of social control to enforce staff compliance with safety protocols.

Mission of Organizational Transformation

PSOs expressed optimism about their efforts to strengthen social relationships, highlighting how communication had improved as a result of the safety projects they introduced. For example, they attributed greater information sharing between departments, frontline staff sharing ideas, and reductions in reports of abusive behavior to their work as PSOs. They saw these improved relations as indicators of greater teamwork, momentum, and buy-in to improve patient outcomes.

Most PSOs had concerns about the entrenched hierarchy that defined relations among hospital staff:

There would be instances here—and I’m sure it goes on other places—where if a nurse spoke up, she was fired. If it was a conflict between a doctor and a nurse, out the nurse went. So that’s some ugly stuff that people have lived through. (PSO, Northeast hospital # 5)

PSOs are well positioned to observe how the history of hierarchy and power differentials in hospital staff creates a sense of fear among nurses. Even as the organization attempts to shift from punitive to accountable hospital models, nurses fear reprisal if they speak up and report error. This entrenched hierarchy between surgeons and nurses impedes the implementation of any model of patient safety that presumes all staff have an equal stake in changing clinical practice. Some PSOs had succeeded in alleviating fears about negative repercussions and protecting staff from retaliation:

And he’s like, absolutely. If you just have to write it on a sticky note or a napkin or anything, let me know, I want all of the information possible. And I think when he just sort of laid it out like that, I think a lot of people were like, oh, that’s good. And I think there’s been a lot more reporting in the last couple of months because of that. (Nurse, Southwest hospital #1)

In the aforementioned extract, the PSO is trying to elide formal documentary procedures to protect staff from formal and informal retaliation and to encourage error reporting, but the fears that staff raised in the previous section show the pervasiveness of staff’s reservations about error reporting.

For most PSOs, encouraging physician buy-in to patient safety reform was the most important, but most challenging, aspect of their work and to their efforts to build bridges across professional divides:

I mean, when something happens and you don’t really want to tell the chief of orthopedics he’s doing something wrong, but if you’ve been empowered by the committee and by me and by our chair to say something. I mean, he’s coming through cause he’s busy. He’s not thinking. Just sometimes a reminder is all you need. It’s like trying to get everybody to wash their hands when they come in and out of patients’ rooms. I mean, you just, you need the elbow more than you need a whip. (PSO, Northeast hospital #1)

PSOs do not have the authority to establish rules for surgeons and ensure they comply with them. The one quoted previously relies on the authority of a safety committee made up of surgeons and senior administrators to nudge surgeons in the appropriate direction.

Other PSOs, however, have adopted a more confrontational model:

I think that some of the surgeons like Dr. M that was there, he tends to talk a lot about himself and doesn’t allow other people to interject and so I took him aside after the first subcommittee last, 2 weeks ago, cause it was all about him kind of thing and I said you know what Dr. M, you can’t do it. I said, you need to let other people speak. You have to empower them to open up. It can’t be just about you. And he said, I did that? I said, yep. So, you know, it’s really a one to one bringing awareness to people and giving them solutions on, you know, being direct. I am a firm believer in being direct. Truth is truth. And I’m sorry if it’s a little harsher than you want to hear it, cause I don’t smooth it over nicey nice; I’m just not built that way. (PSO, Northeast hospital #5)

Several PSOs, women who had been working in health care for decades, emphasized the importance of being direct and firm. This approach, however, has mixed results: The PSO in the aforementioned excerpt was laid off in the year between our first and second visit, and other PSOs discussed how they had been censured by their bosses for being outspoken: “I get written up, boss tells me to be less direct” (PSO, West Coast Hospital 2). These experiences suggest that safety officers are being placed in positions where they see what change needs to happen but are ill-advised to challenge physicians directly unless they have the backing of senior physicians.

Discussion

Strengthening patient safety protocols in health care paved the way for a new occupational role, PSO. Our interviews with PSOs at numerous hospitals uncovered tensions at work between PSOs’ core work role and their broader occupational mission. PSOs perform a combination of technical tasks, including setting up reporting systems to measure health care-associated infections and disseminating these findings to external administrative agencies. They also act as social reformers attempting to bridge divides among health professions, to expand participation in safety projects, and to empower subordinate professions, such as nursing, to improve the quality of care. While PSOs believe that data surveillance and social reform are mutually compatible, our findings suggest the opposite. Frontline staff view PSOs with suspicion as a result of their surveillance role, and this suspicion contributes to staff disengagement from initiatives of patient safety reform, thus eroding PSO’s broader mission to promote transformation in clinical care practices.

PSOs’ experiences differ across various provider organizations, ranging from small community hospitals to large acute-care and teaching hospitals; this creates heterogeneity in PSOs’ roles, occupational mission, and the efficacy of their work. We found that PSOs’ core tasks linked to ensuring their hospitals are compliant with quality improvement protocols did not vary by organization; however, PSOs’ sense of mission did vary by hospital. In community hospitals experiencing financial insecurity and staffing shortage, PSOs perform a wider variety of tasks and are frequently overwhelmed. In these hospitals, PSOs feel swamped by audits, which limit the time available to them for other safety work. In contrast, PSOs working in larger acute-care hospitals are part of larger quality improvement departments and experience greater flexibility in the kinds of projects they undertake. However, organizational changes including mergers and changes in leadership have stalled safety initiatives at these hospitals. While organizational differentiation may be consequential for PSOs’ sense of their occupational mission, our study finds that organizational heterogeneity has a lesser impact on their core task as compilers of data who document performance on safety measures.

Conclusion

Patient safety regulations that seek to reinvent clinical practice to reduce health care-associated infections and other adverse events produce contradictions at the local level (Bosk, 2014; Bosk et al., 2009; Neuman & Bosk, 2013; Scott, 1998). To narrow the gap between formal regulations and their application in practice, PSOs interpret and enact safety regulations by building relationships between and within divergent occupational groups (Heimer & Gazley, 2012; Huising & Silbey, 2011; Pflueger, 2015). PSOs are an example of “sociological citizens” (Silbey et al., 2009): nonsociologists who perceive the systemic and relational nature of organizational work.

PSOs’ occupational mission is premised on the understanding that safe patient care requires transforming social relations within the hospital, including levelling professional hierarchy and building relationships across professional specialties to improve communication and cooperation among professionals. Our study contributes to scholarship on relational regulation by showing how contradictions between occupational tasks and broader professional mission may frustrate efforts to narrow the gap between policy ideals and organizational practice (DiBenigno, 2018b; Huising & Silbey, 2011). In our study, PSOs gain authority through their data surveillance role. However, this authority comes at a steep cost, the trust of frontline staff.

Most PSOs in this study had started out as nurses; they then either gained additional credentials to obtain a managerial position or applied for a PSO position in the hospital where they worked as frontline staff. Nursing professionalization has been inextricably linked to patient safety (Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011).Nurses’ direct involvement in patient care and their expert knowledge of care processes positions them well to assume patient safety roles. A more cynical view might suggest that many of the core work activities that PSOs undertake are the scut work (Huising, 2015; Kellogg, 2014) or dirty work (Hughes, 1971) that other health professions are unwilling to undertake.

Nurses’ subordinate status to physicians and hospital administrators places them in a caring quandary (Apesoa-Varano, 2016; Chambliss, 1996; Davies, 1976; Katz, 1969; Reverby, 2001): the tension between altruism and professional autonomy. In our study, we find that these historical tensions embedded in the nursing profession play out in patient safety work. PSOs do not have the authority to compel dominant professional groups such as surgeons or administrators to change their behavior, and thus PSOs countervailing power (Light, 2010) to reform clinical practice is limited.

Our study, however, shows that PSOs use scut work—for example, gathering data on critical incidents and measuring trends in surgical infections and other complications—as a form of relational authority over higher status professions in an attempt to compel these groups to engage in safety reform. This finding contributes to scholarship on how peripheral professions establish relational authority to institute organizational change (Daudigeos, 2013; Huising, 2015; Kellogg, 2014). This work has shown how peripheral or lower status professions use their limited authority derived from their scut work to gain jurisdictional control over safety reform in organizations. Our findings, however, suggest that while quantification and safety data are an effective mechanism to ensure that frontline staff fulfill the hospital’s reporting requirements, these efforts do little to accomplish their broader occupational mission. This study extends our understanding of the consequences of peripheral professions’ relational legitimacy building and the influence of their tactical use of quantification and data management on organizational practices.

One limitation to our study is that our sample of PSOs is biased. Our interviewees represent a sample of only those individuals working for organizations enlisted in a campaign to reduce surgical site infection that were willing to host a site visit by our research team. The resistance to reform that we report is all the more noteworthy, we believe, because of this limitation.

Our findings have implications for understanding how and why hospitals respond to patient safety protocols in a ritualistic fashion. By examining the challenges that PSOs face in accomplishing both their regular work activities and their broader mission, we see another aspect to the debate about ritualism in organizational regulatory compliance (Power, 1999): Even if hospitals actively seek to comply with safety measures, reform of clinical practice remains elusive. If health care organizations are serious about safety, then PSOs need more formal access to power. The role might need to be performed by a surgeon or attending physician. If this is not possible, then PSOs with ties to the frontline should not have to perform data surveillance tasks, as these tasks undermine frontline staff’s engagement in patient safety reform. Furthermore, organizational transformation and broader environmental volatility exacerbate these tensions between safety workers’ role and mission. As hospitals adjust to changes in senior leadership, mergers, and financial uncertainty, safety initiatives may become sidelined or suspended. More research is needed to examine whether compliance with a set of performance measures alone is sufficient to improve quality in patient care and how organizational turbulence interacts with these processes.

Footnotes

Acknowledgments

We thank Ariel Avgar, Adrienne Eaton, Rebecca Given, Adam Seth Litwin, Noel Eldridge, and anonymous reviewers for their helpful comments and suggestions. We are grateful to Robert Brown for copy editing an earlier version of this article. We are thankful to our colleagues from the Surgical Unit-Based Safety Program project team, in particular Sean Berenholtz, Joanna Veazey Brooks, Ksenia Gorbenko, Deborah Hobson, Elizabeth Wick, and the hospitals and staff who participated in this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was from the Agency for Healthcare Research and Quality (AHRQ) ACTION II -- Accelerating Change and Transformation in Organizations and Networks contract Development and Demonstrations of a Surgical Unit-Based Safety Program to Reduce Surgical Site Infections and Other Surgical Complications (HHSA29032001T-Task 5).

Author Biographies

Catherine van de Ruit is an assistant professor at Ursinus College. Her research areas focus on medicine, health policy, and global health. She earned her PhD in Sociology at the University of Pennsylvania and performed postdoctoral research at the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University.

Charles L. Bosk is a professor of Sociology and of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania. His work focuses on the sociocultural dimensions of health care. He was elected to the National Academy of Medicine in 2013 and awarded a John Simon Guggenheim Fellowship in 2018.

ORCID iD

Catherine van de Ruit

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