Assembling Health Care Organizations

The contemporary period is undoubtedly deeply entangled with the advancement of the technosciences, helping human beings to lead a completely different life from that of just a few generations ago. The capacity to move the human body over continents in a few hours, which would have taken months some centuries ago, or the capacity to communicate directly with family or friends on the other side of the globe are, for instance, two accomplishments of technoscience. What would have appeared as mere magic in the medieval period is today barely noticed as technologies such as the aeroplane or the telephone are taken for granted as they become part of the infrastructure of everyday life. When we can travel from London to New York and back in less than 24 hours and still have time for shopping and lunch, we have definitely managed to “dominate nature” in terms of shrinking distances and taming geographical spaces. In the specific domain of the life sciences dealing with biological processes and biological organisms, similar remarkable accomplishments have been reported. Human reproduction is supported by sophisticated in vitro fertilization procedures, humans may acquire new organs from recently deceased individuals, and active molecular substances are brought into the human body, helping to regulate biological pathways that have ceased to function.

Modern, contemporary health care is inextricably bound up with the advancement of first the sciences and then, from the beginning of the nineteenth century, the life sciences including medicine, physiology and chemistry. At the same time as health care needs to be understood within the context of the scientific revolution and the gradual institutionalization of scientific procedures, modern health care is also the outcome of the democratization of health and the emergence of the welfare state. Health care work is not strictly determined by advancement of the life sciences but is also largely a matter of making informed political choices on what actions to take and what areas to target. Being part of the political economy of public health, health care organizations differ across nations and regions, but they share the elementary predicament of making use of limited resources to seemingly unlimited human needs. The later modern period has been referred to as an information society, an attention economy, a post-materialist society, and a wide scope of such defining labels have been proposed. It would also be fair to speak of contemporary, late modern society as a society governed by the possibilities of the life sciences and the possibilities for maintaining life, restoring biological functions and rejuvenating human bodies through various therapies and procedures.

Health care is regarded to be one of the pillars of today’s welfare societies, and an area that concerns citizens, professionals and politicians. It is also an area that is under constant debate and transformation. During recent decades, health care organizations have undergone a number of different reforms and can, in principal, be described as an experimental workshop where various concepts and models are tested. These models and concepts are put forward as solutions to a number of different problems with which health care is wrestling. In the encounter between the solutions that are being introduced and established practice, different institutional logics are set against one another.

Health care has traditionally been organized on the basis of a division along the lines of medical specializations, and characterized by clear demarcations between organizations as well as between units within organizations. These demarcations have largely been based on professional and knowledge-related foundations. The health care reforms of recent decades (i.e., the introduction of New Public Management) have contributed towards strengthening the boundaries, but they have increasingly come to be based on administrative and financial foundations. In the society of today, demands are also being placed on organizations, causing them to become clearly demarcated units, for example in terms of them having to be accountable and transparent. This is causing a refinement of the operational units, for instance through a narrower assessment of the duties falling within the framework of the organization’s tasks. As a consequence of this trend towards clear demarcations, and as an alternative to the traditional organization, process and collaboration as principles for organizing have been put forward in the debate.

Today’s society is often called the knowledge society, and there is a strong conception that what we do must be based on the best knowledge available. Technological development contributes towards the aim that knowledge must be inscribable and storable so that it may be transferred and used in other contexts (i.e., that knowledge must be transferrable in time and space). This is also noticeable in the care sector, where the notion of evidence-based medicine (EBM) has had a major impact. EBM emphasizes that professional work in medicine should be based on scientific criteria in order to reduce uncertainty in clinical practices (Learmonth and Harding, 2006). The basic idea is that the treatments and methods used must be based on the best knowledge available and that it is possible to produce universally valid knowledge. It is thus a matter of how scientific knowledge can be translated into practice. Doing systematic reviews can also be seen as a response to the information overload characterizing today’s society. EBM, then, constitutes a strategy for creating overview and transparency in the flow of knowledge. Additionally, it is becoming more and more common for knowledge, which is summarized and translated into guidelines and methods, to be inscribed into computer-based programs. The notion of evidence-basing has also gained an increasingly prominent role as regards policy formulation, research agendas and during the allocation of financial resources, enabling us now to talk sooner about evidence-based activities in health care (Lambert et al., 2006).

During recent decades, organization scholars have shifted their focus of attention away from organizations as stable entities, divided from their environments by boundaries, towards organizing as a process, making it possible to understand how organizations emerge and are accomplished (e.g., Weick, 1979; Feldman, 2000; Weick et al., 2005). From such a perspective, organizations are seen as temporary reifications as the process of organizing never ceases (Czarniawska, 2002b). In this chapter we report on a study of the role of organizational boundaries with regard to an occurrence of a critical incident at a Swedish hospital¹: the failure of a drop infusion pump. We studied the investigation of the incident and the efforts made to prevent any similar occurrences. As it turned out, the investigation was not restricted to one specific organization, but involved different organizations, units and groups of people. The aim of the chapter is to describe and discuss the role of boundaries and how they are constructed, deconstructed, reconstructed and stabilized as part of the ongoing process of organizing health care.

Traditionally the health care sector has been characterized by the dependence of strong professional groups organizing, evaluating and delivering the health care services. Such professional work has often been attributed to the individual body, where professional know-how and skills are to be found. Reporting on a study of nursing work in a leukaemia ward of a Swedish regional hospital, it has been demonstrated that the conventional view of nursing as primarily involving bedside care, organized around the patient and through social relations, accommodates only a subset of nurses’ work. In addition to face-to-face care and patient interaction, nursing work is the melding of a great number of actors with different domains of expertise to safeguard the health care status of the patient, spatially distributed, temporally fragmented, and performed and mediated through the utilization of a number of material resources and technologies outwith the everyday lives of the patients.

The title of this book includes the word ‘assembling’, a term that we shamelessly poached from Latour’s (2005) introduction to actor-network theory. The verb assembling is a evocative term as it suggests that something is being brought together, compiled, put into action in an almost haphazard manner, as a form of bricolage or tinkering, using what is at hand. Such a view of ‘the social’ (Latour, 2005) or health care work is in conflict with common-sense thinking assuming that society is once and for all firmly being settled. As, for instance, Carruthers and Babb (1996: 1556) remark, social institutions such as money works best when they can be taken for granted, when they can simply be assumed. Institutions also rest, Carruthers and Babb (1996: 1558) argue, on the combination of naturalization and forgetfulness — a mindful forgetting of the work and negotiations initially needed to put the institution into place. Against such views, the verb assembling is indicating an entirely different view, a dynamic and fluid image of how society and social organization is an ongoing accomplishment characterized by the continuous mobilization of equally abstract and concrete resources. In the first two chapters of the book, the principal resources mobilized in health care work are institutional resources, the totality of abstract norms, beliefs, ideologies, assumptions guiding and structuring everyday work, and material resources, the tool, machines, equipment, biological specimens and so forth, being used.