In recent times, hospitals and healthcare organizations have become more accepting of using human-centered approaches, including ethnography, to lend insight on how to prevent risk, increase efficiency, improve staff experience, and advance delivery of care. But often times, these approaches lack the tools and techniques needed to carry these insights to implementation. This paper identifies and reflects on the hurdles that make change and innovation difficult and how the integration of practices, such as quantitative, co-creative, and change management, with ethnographic methods can help facilitate responsive and sustainable transformation in healthcare organizations.
Introduction | A Call to Action
Past EPIC papers and presentations have highlighted the changing value of ethnography, as Bezaitis and Anderson (2011) lay out: “Our job is not simply to look at the world and report the facts or ‘insights’ in connection with what we see.” Due to changes in the kinds of questions being asked and business problems to solve, we must change how we work in order to remain effective. They call for more from us as ethnographers – more disciplinary approaches, tools, and methodologies that we can use to uncover the ‘truths’ that ultimately help to drive change in the world around us.
We have heard this call for action, and we are responding. Renewing workplaces and organizations requires the keen insight that ethnography produces in order to uncover the truths about behaviors, interpersonal dynamics, and underlying cultural norms that are specific to the organization. However, renewal takes more than just insights and recommendations. We must take steps to restore or repair the components that need an overhaul – it requires action. Can ethnographic insights alone produce action? Perhaps, but in order to achieve renewal in organizations effectively and efficiently, we must go beyond our typical presentation of insights and recommendations. We must bring about action in the form of aiding in the implementation and maintenance of new practices.
Thus, it is this adoption of action that requires us, as practitioners of ethnography, to push ourselves into new territories and acquire new skills and approaches to effectively renew workplaces. We can be most valuable when we are able to support ethnographic insight with methods that help to uncover truths as well as enable change and renewal within the workplace. We believe this interdisciplinary approach is especially necessary in the area of hospital and healthcare renewal – a workplace where complexity is the norm, human lives are at risk, and enacting lasting change has been a notoriously difficult task.
Understanding the Complexity of the Healthcare Setting
Our focus for this paper is the improvement, transformation, or renewal of hospital processes to enrich the human experience (whether that focuses on patients, professionals, or both) without jeopardizing the quality of care or safety of the patient. This turn to renewing the healthcare and hospital experience is becoming a particularly relevant subject in recent times since hospitals are increasingly understanding the value of the human experience. As the worldwide population increases in size and diversity, traditional models of care are struggling to adapt in the face of systemic obstacles to change (Parameswaran & Raijmakers, 2010). This, in turn, leaves patients unhappy, staff overworked, and administrators overwhelmed, which results in healthcare systems that prioritize efficiency over excellence. Ultimately, the healthcare system is in crisis and needs new strategies for innovation that will allow for sustainable success in the face of innumerable challenges. These challenges are an outgrowth of a healthcare industry that is complex, confusing, and at times archaic.
It is incredibly difficult to navigate these complexities when organizations are being tasked with bringing change and renewal to the delivery of care. There are many barriers that ‘change enablers’ encounter at different levels of a healthcare system or hospital.
At a systems level, healthcare is a product of its political and economic environment, which means that factors that influence patient care are coming from many different directions (Reid et al., 2005). These factors, which include financial and regulatory entities, may not always support a human-centered approach to healthcare delivery (Bissent & Maher, 2009). Yet facilities are expected to balance financial and legal constraints while continuing to provide quality patient care.
At an organizational level, communication of information between departments and units tends to be fragmented. Critical information-gathering is distributed between various units, each with its own objectives, obligations, and capabilities. Patient care benefits from a seamless flow of information within and across these entities, however this is rarely achieved. Whether this is a consequence of the information technology employed (such as EMR/EHRs) or the inconsistent communication between staff members, these barriers can create negative perceptions and infighting within and between departments that can lead to an unsuccessful change initiative (Cebul et al., 2008).
At a cultural/social level, staff and administrators tend to rely on evidence-based research to make decisions about healthcare guidelines and standards. While this approach is thought to reduce variations in practice – thus reducing potentially negative consequences in the organization – it can in fact undervalue tacit knowledge that practitioners have honed over years of experience (Gabbay & le May, 2004). In addition, these evidence-based guidelines are based on systematic scientific research studies. More qualitative approaches, including ethnography, do not always fit within the narrow parameters of what is said to be ‘evidence’ (Hjørland, 2011). Thus, qualitative methods, while becoming more established in some areas (such as nursing), aren’t always accepted as a relevant or satisfactory method of investigation and insight (Brooks, 2007).
At an attitudinal, cognitive, or motivational level, practitioners and staff members have differing – and sometimes conflicting – priorities. These differences in priorities may be due to a lack of awareness or knowledge or a lack of motivation to change their routines (National Institute of Clinical Studies, 2006). Either way, the siloing of departments, as discussed earlier, can escalate this issue of opposing priorities. Without understanding what priorities motivate each group, consensus on important insights and the ‘truth’ of what goes on will be nearly impossible to achieve.
In sum, bringing renewal to healthcare systems and hospitals require strategies that can enable change at each of these levels – strategies that will allow them to reshape processes and practices that were instituted decades ago and based on an outdated model of care. We believe that ethnographic methods are crucial to forming these strategies, which must not only seek to understand the cultural core that makes change so difficult, but also be generative of methods to encourage transformation and renewal.
The Changing Value of Ethnography in Renewing Workplaces
According to Atkinson (1994), ethnography was originally employed to contribute to disciplinary knowledge rather than solving practical problems in the world. The intent was to provide an account of the ‘truth’, which was seen as valuable in its own right. We believe the goal still holds true that the production of knowledge is intrinsically valuable. However, to truly renew the workplace we must go beyond the idea of research as outcome to research as input to solutions.
As discussed earlier, the culture of the staff as well as the organization as a whole plays a huge role in carrying through effective changes in practice. Ethnography has slowly been gaining more traction in healthcare as an approach that can bring these cultural and social implications to light, which in turn can help inform the creation and implementation of transformational changes.
Not only can ethnography help to uncover behavioral practices and routines, but it can help us, as researchers, uncover strategies for realigning expectations across siloed teams. It can also uncover strategies for increasing buy in and ownership of these changes. Ethnography as a stand-alone practice is particularly well-suited for gaining insight into the current behaviors and practices that are needed to launch a change initiative. It is also a great tool for helping healthcare providers understand their context and the challenges associated with the system they operate within by exposing the true practices and behaviors that occur. But within the healthcare setting, ethnography alone isn’t always enough to carry the proposed changes through to implementation and adoption.
Renewal in organizations means redefining our work
Traditionally, researchers would do the bulk of the work and encourage the client to participate if they so desired. After providing insights and recommendations, the researchers were generally no longer involved in the process and the client would move forward to develop, implement, and revise solutions, often times enacting more innocuous recommendations that may miss the key essence for success.
As we move into renewing the workplace, rather than just consumer goods and services, we must ensure that the most impactful ideas aren’t swept under the rug by becoming embedded teammates with our clients in the journey of renewal. We can equally share the responsibility for research and improvement. We can continually empower our clients by working in lock-step with them from research through implementation.
Thus, as researchers, we must continue to evolve our roles, skills, and impact on the transformative work that we provide to organizations. We can no longer simply pass off our insights and recommendations and rely on our clients to carry through these changes. If we are to be ‘change enablers’ that bring about renewal in organizations, we must become part of the implementation process. How many of us have provided insights, only to become unsure what has become of them – or worse, to watch them flounder and sink in an organization? While we strive to create recommendations that are ‘actionable’ for our client, we don’t hold any power in ensuring that any action is, in fact, taken. If we believe our insights are ‘truths’ and our recommendations are solutions, then we should either expand our role through implementation of these solutions or ensure our clients have the capability to adopt and advocate for transformation – or better yet, use both strategies to see change realized and help create structures that can be self-responsive to change in the future.
In order to adopt this ‘action stance’, we must utilize additional approaches and skills, especially when it comes to the complex hospital workplace.
Supporting qualitative insights with quantitative data
As discussed earlier, most healthcare professionals rely on evidence-based research, which tends to be quantitative in nature. As Barbour (2001) argues: “The question is no longer whether qualitative methods are valuable but how rigor can be assured or enhanced.” Quantitative data, whether they are gathered through the IT department’s metrics database or simply collecting metrics of our own, can help support qualitative insights gained from ethnographic methods. This triangulation of insights and data helps to bring the ‘rigor’ that Barbour mentions, essentially ‘validating’ the qualitative findings from ethnographic work. This is especially important when dealing with particularly contentious issues.
Another benefit that quantitative measurement brings to healthcare change initiatives is that it allows us to track the changes being made – whether positive or negative. By creating a baseline of data that is relevant to the proposed changes before they are launched, we can compare those to metrics captured at different points during and after the change initiative. This ability to evaluate measured improvement, or decline, is particularly important for healthcare systems. In order to disseminate change initiatives to other hospitals, changes must be recognized as effective and defensible.
Quantitative data can be a powerful tool to lend rigor and depth to qualitative insights. However, when the quantitative and qualitative insights are conflicting, it can be difficult to uncover the ‘true’ story. A hard look at the quality of both types of data can help to reconcile this concern.
Co-creating the vision with ‘experts’
After uncovering insights, we traditionally develop recommendations for change based on our ‘expert’ knowledge gained from hours observing and interviewing, without input from those that know the work best. While we may spend hundreds of hours observing in the hospital, we will never be as knowledgeable as those from which we are learning. Fortunately, we can harness this foundational knowledge through co-creative methods. Co-creation, or the approach of actively involving all relevant stakeholders in the creative process, fits in where ethnography leaves off. The stakeholders are truly the experts of their domain, so creating solutions that are based around their perspective can help carry the initiative through to implementation and adoption successfully.
This approach not only allows the stakeholders’ expertise to be gathered but also allows greater customization of the initiative. Making solutions easily customizable is particularly important for initiatives to be successfully adopted within and across hospitals and healthcare systems since they account for differences in the culture of the organizations and professional domains. It lessens the role of the researcher and increases the stakeholders’ roles as the creators of their future.
An important aspect of the success of co-creation is ensuring the ‘right’ people are included in the process. Due to the typical siloing of departments and units within a hospital, it is critical to include a cross-section of management, administration, practitioners, staff, and even patients. This cross-sectional team can help bridge the divide between units to share knowledge and expectations that aren’t always communicated in the hospital environment. It also increases empathy between teams and units, so they can understand each other’s perspective of the process to reduce unfounded perceptions or in-fighting.
So what does it look like to co-create a process? We have found the most effective communication tools are ones that are able to communicate very detailed information while showing the overarching process. Journey maps have been effective for us to do just that – to show every touch point in the experience as well as the people involved, tools used, and potential opportunities for improvement. This document builds situational awareness and acts as a source for subsequent activities. This mapping however is not meant to be a product. Rather, it is a means to an end and a way to frame and inspire change.
Facilitating renewal with change management techniques
We, as researchers, tend to use our skills for sense-making rather than actual transformation. As Holme (2010) asserted in a previous EPIC paper, this may be attributed to our reluctance to impose changes on people’s lives. This leads to insufficient guidance in the creation of impactful and lasting changes within an organization since our preference is to tell people’s stories rather than open up new opportunities for transformation.
We know both what needs to be changed through ethnographic insights and quantitative data and how to plan for change using a co-creative approach to construct a new process. We now need to create the optimal conditions in which innovative changes can be implemented and sustained. While we know change is difficult, we can make use of our cultural sensitivities to facilitate organizational changes. As Blomberg (2011) states: “Employees, change agents, and clients can avoid some of the pain often experienced when new process, policy, or technology standards are introduced by viewing change as an iterative process that grows from the inside out, even when the transformation is defined from the top down.” This is essentially the role of change management.
Change management is a set of tools, processes, skills, and/or principles for managing the people-side of transformation in order to achieve a desired goal or outcome. There are many different models for how to successfully manage change within companies (Booz & Co., 2004; Burnes, 2004; Kotter, 1996), but they all tend to have a common strategy. First is to shake up a hardened status quo, then introduce the new practices, and finally firmly incorporate changes into the organization’s culture.
The first step of shaking up the status quo helps to prepare individuals, as well as the organization, for change. To do this, establishing a sense of urgency helps to counteract inertia and complacency that can thwart effective change initiatives. Ethnography, along with quantitative findings, can aid this undertaking by tracking and uncovering the cause and effect of certain practices so staff may understand the true implications of their current behaviors at a holistic level. Ultimately, they can become aware of how and why these implications are important as well as how they may affect values that are important to them – whether it’s efficiency, safety, quality of patient care, or other.
The next step of introducing new practices is where new skillsets for researchers can come into play. The creation of these new practices may come out of co-creative sessions with the work team, but they still need to be communicated and disseminated to the rest of the staff in a clear and consistent manner. By using ethnography to map and track valuable communication channels, we can enlist these insights to naturally and effectively circulate new practices. Developing an iterative approach to new practices, such as a rapid cycle change, allows us to test and quickly modify proposed changes by understanding what is working and what isn’t. By testing and refining, it helps to build momentum in the organization and allay people’s fears about being stuck in process changes that will actually do more harm than good.
Finally, in order to firmly incorporate new practices into the organization must be anchored into the culture by supporting changes to behavior norms. Again, the employment of ethnographic insights can help guide us to appropriate courses of action that will uphold the work we have done. These strategies may include additional training sessions with staff, verbal support by supervisors and management, or reworking of evaluation and promotion criteria. This may be seen as a more controversial step in renewal since we are seeking to actively change the workplace culture, but it is at this point in the process where the changes will be sustained even after our work is complete. This is where we can ensure that the transformation is complete.
A NOTE ON ETHICS
This action-oriented process we have laid out above goes against our very nature as ‘participant-observers’ – that is, we are calling for a change to the very culture of the group we are studying. Thus, it is imperative to revisit the ethical implications of our work to understand the risks to participants Hammersley & Atkinson (1995). It is our ethical duty to ensure that participants are not harmed or exploited during this process, though it is clear that changes can produce distress. Ethical dilemmas are a contentious issue and are mostly based on individual judgment, but if we can determine that the importance of the change outweighs the consequences, then at least we are making a reasonable effort to uphold our ethical duties. In sum, if we are taking on the responsibility of action, then we must take responsibility for our actions.
As hospitals and healthcare systems start to move away from top-down mandates for organizational change and process modifications and towards a bottom-up human-centered approach to renewal, our skills as ‘agents of change’ are continually being enlisted. We can agree that bringing renewal to the workplace is challenging – not only for the organization but also for us as researchers and ethnographers. To remain effective and valuable, as well as to truly enable successful change, we must be willing to renew our practices and ourselves. There is still much work to be done to redefine our roles when tasked with organizational renewal as we evolve from problem-seekers to problem-solvers to solution-realizers. Additionally, using ethnography as a means to renew an organization or workplace can involve significant ethical dilemmas if the research isn’t approached with care and consideration. In any case, we hope this paper helps to encourage ideas about ways in which we can help enact change in organizations and workplaces by adopting a stronger responsibility of action for ourselves.
Lindsey Messervy is a design researcher and strategist who seeks to improve people’s experiences with products, services, and technology in a variety of industries. Her work at Business Innovation Factory focuses on enabling transformation within the social systems of healthcare, education, entrepreneurship, and citizenship.
Beth Werner is a researcher and strategist with a focus on service design for health care delivery. She is currently working with Ximedica, a design consultancy, based in Providence.
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